THE    ROENTGEN    RAYS 
IN    MEDICINE    AND    SURGERY 


^3^^^ 


THE  ROENTGEN  RAYS 


IN     MEDICINE     AND     SURGERY 


AS    AN    AID    IN    DIAGNOSIS    AND    AS 
A    THERAPEUTIC    AGENT 


2DfgignfJ)  for  tbc  Clsc  of  ^^3ractitionfr0  anD  ^tuDcnts; 

BY 

FRANCIS    H.  WILLIAMS,  M.D.  (Harv.) 

Graduate  of  the  Massachusetts  Institute  of  Technology ;    Visiting  Physician  at  the  Boston  City 

Hospital;  Fellow  of  the  AJassachusetts  Medical  Society  ;  Member  of  the  Association  of 

American    Physicians;    Member   of  the  American   Climatological  Association ; 

Fellow  of  the  American  Association  for  the  Advancement  of  Science  ;  Fellow 

of  the  American  Academy  of  Arts  and  Sciences,  etc. 


WITH  FOUR  HUNDRED  AND  TWENTY-EIGHT  ILLUSTRATIONS 


THIRD  EDITION.     WITH  ENLARGED  APPENDIX 


THE    MACMILLAN    COMPANY 

LONDON:    MACMILLAN    &    CO.,    Ltd. 
1903 

All  rights  reserved 


Copyright,  1901,  1903, 
By  the  MACMILLAN   COMPANY. 


Set  up  and  electrotyped  November,  1901.     Second  edition,  with  additions, 
March,  1902.     Third  edition,  with  additions,  May,  1903. 


Norzuood   Press 

J    S.   Gushing;  &  Co.  —  Berivick  &  Smith  Co. 

Norwood,  Mass.,  U.S.A. 


Biomedical 
Ukaaj 

WW 

100 

PREFACE 

The  following  pages  are  rather  a  report  of  progress  than  a  final 
presentation  of  this  growing  subject. 

I  planned  to  include  as  complete  a  list  as  possible  of  the  publi- 
cations on  the  medical  and  surgical  uses  of  the  Roentgen  rays,  but 
when  it  was  found  that  the  list  would  add  nearly  one  hundred  pages,  it 
was  omitted  ;  had  I  foreseen  this,  I  should  have  referred  in  the  text 
to  many  other  important  papers. 

My  own  contribution  is  the  result  of  two  opportunities.  The  one, 
by  permission  of  Professor  Charles  R.  Cross,  was  in  the  Rogers  Labora- 
tory of  Physics  of  the  Massachusetts  Institute  of  Technology.  With 
the  most  cordial  and  efficient  assistance  of  Messrs.  Charles  L.  Norton 
and  Ralph  R.  Lawrence,  of  this  department,  I  obtained  my  first  equip- 
ment at  a  time  when  many  difficulties  had  to  be  ov^ercome.  From  the 
late  Professor  Emeritus  S.  W.  Holman,  whose  rare  character  and  abil- 
ity made  itself  felt  by  all  who  had  the  good  fortune  to  be  his  friends, 
I  have  sought  and  received  both  advice  and  assistance  during  the 
course  of  my  studies. 

The  other  opportunity  has  been  at  the  Boston  City  Hospital.  To 
my  colleagues  on  its  staff  I  am  indebted  for  the  interest  they  have 
shown  by  referring  to  me  from  their  services  many  patients  requir- 
ing X-ray  examination  or  treatment. 

,,      In  the  reproduction  of   the  X-ray   photographs  there  has  been  no 
;^etouching. 

^  I  wish  it  were  possible  for  me  to  express  the  gratitude  I  feel 
^toward  Dr.  WiUiam  Rollins  for  his  unfailing  aid  in  my  efforts  to  obtain 
"^apparatus  suitable  for  these  examinations,  and  particularly  for  the  new 
Cand  better  forms  of  vacuum  tubes  that  he  has  devised. 
^  It  is  my  privilege  to  express  my  obligation  to  my  wife,  for  her 
r^devoted  assistance  in  the  preparation  of  this  book. 


505  Beacon  Street, 
Boston,  Massachusetts,  1901. 


624458 


PREFACE    TO    SECOND    EDITION 

The  first  edition  was  unexpectedly  exhausted  within  three  months, 
and  there  has  been  but  Httle  time  in  which  to  prepare  a  second ;  some 
forty  pages  have  been  added,  however,  chiefly  on  apparatus  and  the 
therapeutic  uses  of  the  X-rays,  which  will  be  found  in  the  Appendix. 

March;  1902. 


PREFACE    TO    THIRD    EDITION 

The  therapeutic  uses  of  the  X-rays  have  grown  so  rapidly  in  impor- 
tance that  for  this  edition  I  have  rewritten  and  enlarged  the  appendix, 
and  have  devoted  the  greater  part  of  it  to  the  X-rays  as  a  therapeutic 
agent.  The  method  of  treating  diseases  of  the  skin  and  of  new  growths 
is  described,  and  a  table  of  150  of  my  cases  of  the  latter  is  given  and 
discussed.  The  last  twelve  pages  contain  a  list  of  articles  on  the 
therapeutic  uses  of  the  X-rays  and  X-ray  dermatitis. 

March,  1903. 


TABLE    OF   CONTENTS 


CHAPTER    I 
Nature  and  Properties  of  the  X-Rays 


Origin  and  nature  of  the  X-rays    ..... 

Properties  common  to  X-rays  and  to  light     . 

Properties  in  which  the  X-rays  appear  to  ditler  from  light 

Property  of  the  X-rays  of  peculiar  value 

Law  of  absorption         ....... 

Atomic  weight      ........ 

Absorptive  power  of  fat,  muscles,  bones,  etc.,  of  the  body 
Absorptive  power  of  air  and  gases  ... 

Opacity  of  blood  to  X-rays  compared  with  that  of  water 


PAGE 

I 
I 
I 

2 

2 
2 

3 

4 
6 


CHAPTER    II 


X-Ray  Equipment 


Static  machines    .... 
Induction  coils      .... 
Portable  apparatus 
Generator  for  isolated  situations    . 
Vacuum  tubes  : 

Proper  forms 

Resistance  of  tube 

Methods  for  changing  resistance 

Tube  holder 

Diaphragm     . 
Fluorescent  screen 
Fluoroscope 
Photographic  plate 
Bromide  paper 
Precautions  to  be  taken  when  using  X-ray 

nations       ..... 
Harmlessness  of  X-ray  examinations  if  prope 


apparatus  and  making  X 
r  precautions  are  taken 


ray  e.xami- 


8 

19 

27 

31 

32 

42 

44 
47 
47 
54 
56 
56 
57 

58 
58 


TABLE   OF    CONTEXTS 


CHAPTER   III 
Methods  for  making  X-Rav  Examixatioxs  with  the  Fluorescent 

SCREEX   AND   X-RaV   PHOTOGRAPH 


Support  of  patient         ...... 

Relative  position  of  patient,  tube,  and  screen  or  plate 
Method  of  securing  a  constant  position  for  the  target 
Examination  of  patient  lying,  sitting,  or  standing 
General  rules  for  examination  with  fluorescent  screen 
Methods  for  recording  appearances  seen  on  fluorescent 
Methods  of  localization  ..... 

Method  of  examination  by  X-ray  photograph 
Examination  with  screen  before  photograph  is  taken 
Position  of  plate  in  photographing  different  parts  of  the  body 
X-ray  negatives  compared  with  X-ray  photographs 
Length  of  exposure       ...... 

Importances  of  two  views      ..... 

Comparative  advantages  of  screen  and  photograph 


CHAPTER    IV 


Introduction  to  Thorax 

General  view         ..... 
Normal  lungs        ..... 
Experiments  with  abnormal  lungs 
Clavicles  and  ribs  .... 

Standards  of  measurement.     Densitometer 
Diaphragm  lines  ..... 
Average  normal  excursion  of  diaphragm 

Heart 

Blood-vessels        ............. 

Relative  usefulness  of  fluorescent  screen  and  X-ray  photograph  in  e.xaminations  of 
the  thorax ..... 


CHAPTER   V 
Pulmonary  Tuberculosis 


Appearances  seen  on  the  fluorescent  screen  : 
Darkened  lung       .         .         .         .         . 
Restricted  excursion  of  diaphragm 
Displaced  heart      .         .         .         .         . 
Illustrative  cases    .         .         .         .  . 

Appearances  seen  in  early  tuberculosis 


TABLE    OF    CONTENTS 


Definition  of  early  tuberculosis 

Directions  for  making  X-ray  examinations 

Comparative  value  of  fluorescent  screen  and  X-ray  photograph 

Usual  means  of  diagnosis 

Early  physical  signs  at  apex 

Tuberculin  test     ..... 

Test  for  tubercle  bacilli 

X-ray  examination  an  aid  in  early  diagnosis 

Diagnosis  not  made  by  X-rays  alone     . 

Final  test  tubercle  bacilli 

Classes  of  cases  in  which  X-rays  are  of  value 

As  an  aid  in  diagnosis   . 

Old  lesions  of  tuberculosis 

More  accurate  determination  of  existing  conditions 

Determining  progress  and  extent  of  disease 
No  signs  by  X-rays  in  two  cases  of  tuberculosis 
Prevalence  and  mortality  of  tuberculosis 
Hopeful  prognosis  where  there  is  early  diagnosis 
Importance  of  X-ray  examination  in  young  people  under  certain  condition; 
Use  of  all  three  methods,  auscultation,  percussion,  and  X-ray  examination 


PAGE 

117 
117 
120 
120 
121 
121 
121 
122 

123 
124 
125 
148 
149 
151 
158 

159 
160 
162 
163 


CHAPTER    VI 


Pneumonia 


photograph 


Introduction  ........ 

Appearances  seen  in  pneumonia  on  the  fluorescent  screen : 

Darkened  lung       ..... 

Diaphragm  lines     ..... 

Displacement  and  enlargement  of  heart 

Usual  region  affected      .... 
Method  of  examination  .... 

Comparative  value  of  fluorescent  screen  and  X-ray 
Outline  of  pneumonia  sharply  defined   . 
Persistence  of  X-ray  signs     .... 
Excursion  of  diaphragm  limited  by  adhesions 
Pneumonia  with  obscure  physical  signs 
Differential  diagnosis  : 

Pleurisy  with  eiTusion  or  pneumonia 

Pneumonia  or  tuberculosis 
Pneumonia  with  ••  la  grippe  "... 
Severe  cold  ....... 

Empyema  overlooked   ..... 

Appendicitis  confounded  with  pneumonia 
Absence  of  pneumonia  determined 
Broncho-pneumonia      ..... 


164 

164 
167 
167 
167 
168 
169 
173 
174 
180 

183 

186 
191 
191 
192 
192 
192 
192 
192 


TABLE   OF   CONTENTS 


CHAPTER  VII 

Emphysema  of  the  Lungs.     Bronchitis 

Emphysema  of  the  Lungs 

Appearances  seen  on  the  fluorescent  screen  in  emphysema  of  the  lungs  : 

Lungs  brighter  than  normal   .......... 

Diaphragm  lower  down  in  chest ;  movement  restricted  on  upper  side 
Heart  lower  down  and  its  long  a.xis  more  vertical ;  its  position  changed  less 
between  inspiration  and  expiration      ........ 

Successful  use  of  percussion  hindered  by  emphysema    ...... 

Physical  signs  of  tuberculosis  hidden  by  emphysema;  abnormality  of  lungs  seen 

by  X-rays 198 

Bronchifis 

Appearances  seen  on  fluorescent  screen  in  bronchitis    ......     200 

Foreign  body  in  bronchus  suggests  reason  for  appearances  seen  in  chest  by  X-rays     200 


193 
193 

193 
198 


CHAPTER    VIII 


Pleurisy  with  Effusion.     Empyema 

Appearances  seen  on  the  fluorescent  screen  in  pleurisy  with  eftusion 
Methods  of  examination        ......... 

Untrustworthiness  of  percussion  in  determining  the  presence  of  fluid  in  the 
by  means  of  a  displaced  heart     .... 

Encysted  pleurisy  ....... 

Interlobar  empyema  or  pleurisy     ..... 

Diaphragmatic  pleurisy  ...... 

Pleurisy  with  efTusion  and  emphysema 

Pleurisy  with  effusion  and  pneumonia    .... 

Pleurisy  with  effusion  and  pulmonary  tuberculosis 
Pleuritic  adhesions        ....... 


chest 


202 
205 

213 
216 
218 
218 
218 
218 
222 
229 


CHAPTER  IX 


Hydrothorax.     Pneu.mothorax.     Empyema  with   Permanent  Opening. 
Pneumohydro-  or  Pneumopyothor.\x 


Appearances  seen  on  fluorescent  screen  in  hvdrothorax  : 

Lower  portion  of  chest  darker  than  normal  :  darkened  area  extending  higher 
if  disease  is  more  marked  :  outlines  of  diaphragm  obscured  or  obliterated  . 
Appearances  seen  on  fluorescent  screen  in  pneumothorax  : 

Affected  side  of  chest  clearer  than  normal       ....... 

Diaphragm  pushed  down        .......... 

Organs  displaced  to  opposite  side 


234 

234 
234 
234 


TABLE   OF   CONTENTS 


Method  of  examination  . 

Method  for  withdrawing  air    .........         . 

Improvement  watched  by  fluorescent  screen  ....... 

Empyema  with  permanent  opening 

Appearances  seen  on  fluorescent  screen  in  pneumohydro-  or  pneumopyothora.x  : 

Sitting  position.     Chest  resembles  tumbler  half  full  of  ink.     Heart  displaced 
to  opposite  side.     Lung  on  affected  side  retracted       .         .         .         .         . 

Recumbent  position.     Aff"ected  side  of  chest  dark  throughout 

Improvement  watched  by  fluorescent  screen  ...... 

Immediate  relief  by  operation 


PAGE 

235 

239 
241 


241 
244 
244 
245 


CHAPTER   X 


Heart 


Section  I.     Normal  and  Abnormal  Heart 

Conditions  necessary  for  seeing  the  heart      ........  247 

Appearances  seen  on  the  fluorescent  screen  in  the  normal  heart,  with  patipnt  lying 

on  his  back         ............  247 

Pulsations     ...........         ^         .         .  249 

Ape.x  beat 252 

Experiments  made  by  Ludwig  and  Hesse  on  the  form  of  the  heart  in  systole  and 

diastole      .............  253 

Position  of  blood  vessels  and  borders  of  heart  studied  at  autopsies  .  .  -257 
Appearances  on  screen  with  patient  lying  on  his  side  and  light  going  through  him 

horizontally.     Triangle.     Wedge-shaped  space  ......  258 

Width  of  normal  heart           .          .          .         .          .         .         .          .         .         .  260 

Location  of  right  and  left  borders  of  heart  by  distance  from  median  line        .         .  260 

Width  of  heart  in  relation  to  height  of  individual  .          ......  261 

Appearances  seen  on  the  fluorescent  screen  in  abnormal  heart       ....  262 

Instrument  for  observing  heart  while  listenins:  to  its  sounds  .....  262 


Section  II .     Methods  of  Examination 

Intensity  of  light  ......... 

Position  of  patient         ........ 

Recumbent  and  sitting  position     ...... 

Errors  to  be  avoided  in  determining  width  of  heart 
Proper  position  of  tube  and  manner  of  recording  outlines 
Comparative  value  of  photograph  and  screen  in  examination  of  heart 


263 
263 
263 
263 
263 
270 


Section  III.     The  Importance  of  knowing  the  Size  of  the  Heart.     Inaccuracy 
of  Percussion  in  determining  its  Size  as  shown  by  X-Ray  Examination 

Prognosis  and  diagnosis        ........... 

Comparison  of  percussion  and  X-ray  examination  ..... 


270 
272 


TABLE   OF   CONTENTS 


Width  of  heart  obtained  by  percussion  compared  with  weight  of  heart  ob- 
tained at  autopsy.     (Tables)       ••......  272 

Comparison  of  percussion  witii  X-ray  examination  in  determining  width  of 

heart.     (Tables) 273 

Illustrative  cases    ............  28a 

Small  hearts  and  congenital  malformations     .......  283 


ScLtion  IV.     Displaced  Heart 

Causes  of  displacement : 

(<?)   Fluid  or  gas  in  pleural  cavities 
(/^)    Changes  in  position  and  excursion  of  diaphragm 
{c)    Tuberculosis  and  unequal  excursion  of  diaphragm 
{d)  Pneumonia  and  unequal  excursion  of  diaphragm 
(^)    Aneurisms  and  new  growths    .... 
(/")  Contractions  and  adhesions     .... 
Heart  attaclied  ;   movements  unusual  during  full  inspiration 
Displacement  of  heart  simulating  enlargement  by  percussion 
Chlorosis      ......... 


Unusual  positions  of  heart  and  malformations 
Apparent  dextrocardia  .... 


285 
286 
288 
288 
29a 
290 
294 
295 
297 
297 
298 


Section  V.     Other  Abnormal  Conditions  of  the  Heart 

Pulsations     ..............  298 

Pericardial  effusion        ............  300 

Mobility  of  the  heart     ............  301 


Section  VI.     Effect  of  Treatment  7vatched  by  X-Ray  Exafninations 

Improvement  watched  by  X-ray  examination  during  treatment 
Avoidance  of  too  early  cessation  of  treatment         .... 

Enlarged  hearts  with  murmur 

Warning  of  serious  condition  given 

Timely  warning  of  di.sease     ........ 

Want  of  efificient  pulmonary  circulation  shown  by  X-ra3's.     Alcoholics 
Passive  congestion  shown  to  be  absent  by  X-rays 
Precautionary  and  preventive  X-ray  examinations 


302 

305 
305 
305 
306 
306 
308 
308 


CHAPTER    XI 

Thoracic  Aneurisms 

Appearances  seen  on  the  fluorescent  screen  and  by  X-ray  photograph  in  thoracic 
aneurism  : 
Shadow  cast  to  left  or  right  of  sternum,  or  on  both  sides  of  sternum       .         .     310 
Heart  often  displaced  or  enlarged  if  aneurism  is  large     .....     310 


TABLE    OF   CONTENTS 


Difficulty  of  diagnosis  by  ordinary  methods 

Method  of  examination  by  X-rays  ........ 

Early  diagnosis  possible  by  X-rays • 

Aneurism  suggesting  pulmonary  tuberculosis  ;  X-rays  showed  thoracic  aneurism   . 

Aneurism  of  aorta  with  perforation  into  oisophagus.  Aneurism  and  size  of  heart 
as  determined  by  the  X-rays  confirmed  at  autopsy 

Subclavian  aneurism ;  X-ray  examination  before  operation  to  exclude  extension 
below  clavicle.     Result  of  examination  confirmed  by  autopsy 

Diagnosis  of  aneurism  confirmed  by  X-ray  examination 

Aneurism  suggesting  intercostal  neuralgia;  suspected  aneurism  confirmed  by 
X-ray  examination.  X-rays  enable  us  to  determine  whether  an  aneurism 
is  or  is  not  increasing  ......•••• 

Extent  of  aneurism  determined  only  by  X-ray  examination 

Diagnosis  of  aortic  aneurism  by  X-ray  examination  confirmed  by  autopsy.  Posi- 
tion of  left  border  of  heart  obtained  by  X-ray  examination  confirmed  at 
autopsy       ............ 

Aneurism  unsuspected  by  physical  examination  determined  by  X-ray  examination 

Aneurism  unrecognized  by  auscultation  and  percussion  seen  by  X-ray  exami 
nation         ............ 

Aneurism  recognized  only  by  X-ray  examination  ...... 

Aneurism  suspected  on  account  of  hoarseness;  X-ray  showed  no  aneurism  was 
present        .........••• 

Tentative  diagnosis  of  thoracic  aneurism       ....... 

Aneurism  of  the  ascending  aorta  ;  enlarged  heart ;  X-ray  and  percussion  lines 
compared  ;  X-ray  outlines  confirmed  by  autopsy  .... 

Importance  of  examination  by  fluorescent  screen  and  careful  interpretation  of 
X-ray  photograph 


PAGE 

310 
312 
313 

315 
3^7 


319 
^20 


321 

322 

323 
323 

324 

32-^ 
327 
-.28 


CHAPTER   XII 


New  Growths.     Enlarged  Glands.    Abscess  and  Gangrene  of  Lung 


Introduction  .         .  .         .     •     . 

Method  of  locating  a  new  growth  ....... 

Diagnosis  of  new  growth  made  by  aid  of  X-rays  confirmed  by  autopsy 

Tumors  in  chest.     Results  obtained  by  X-ray  examination  and  auscultation  and 

percussion  compared  ......... 

Tumors  in  head    ........... 

Differential  diagnosis    .......... 

X-ray  appearances  of  an  extensive  new  growth  and  an  interstitial  fibrous  pneu 

monia  compared  ......... 

New  growth  in  chest  wall 

Echinococcus  of  the  lung      ......... 

Malignant  disease  of  the  abdomen  ;  question  of  extension  into  thorax  . 


33- 
334 
338 

339 

340 
340 

343 
345 
346 
346 


TABLE    OF    COxN'TEXTS 


A  bunch  of  enlarged  glands  simulating  the  outline  produced  by  an  aneurism  when 

examined  trom  one  direction 

Enlarged  bronchial  glands  ;  disease  extending  into  lungs      .         .         .         .         . 
Abscess  and  gangrene  of  lung 


CHAPTER   XIII 
Conclusion  of  Thorax 

Differential  diagnosis    ...... 

Acute  and  chronic  processes  compared 
Association  of  an  acute  and  chronic  process 
Association  of  two  acute  diseases 
X-ray  examination  of  the  whole  chest,  not  of  one  organ  alone 
X-ray  examinations  made  by  trained  physicians  ;  preferably,  specialists 
diseases      ....... 

X-ray  examination  part  of  physical  examination     . 
Need  of  X-ray  apparatus  by  physicians 


of  thoracic 


CHAPTER   XIV 

X-Ray  Examination  of  the  CEsophagus,  Abdomen,  and  Pelvis 
Qisophagus : 

Stricture  of  the  oesophagus     .... 

Diverticulum  ...... 

Abdomen  : 

Introduction  of  air  or  gas        .... 

Use  of  bismuth       ...... 

Stomach  : 

Methods  for  observing  the  stomach 

Position  of  stomach  when  standing  and  lying  dowi 

Movement  of  the  stomach  during  respiration 

Changes  in  shape  of  stomach  during  digestion 

Physiology  of  digestion 

Digestive  tract  observed  by  means  of  capsules 
Liver    ........ 

Spleen  ...... 

Kidneys        ... 

Ascites  ....... 

New  Growths  : 

Carcinoma  of  the  stomach 

Carcinoma  of  the  liver    .... 

Cancer  of  the  pvlorus     .... 

Phantom  tumors    ..... 
Intestines      ...... 


TABLE   OF   CONTENTS 


Pelvis  : 

Method  for  taking  a  photograph  of  the  pelvis 

Sacrum  .......... 

Measurement  of  transverse  diameter  of  the  pelvis  . 

Gravid  uterus         ......... 

Determination  as  to  whether  a  foetus  has  or  has  not  breathed 


379 
379 
379 
382 

3^5 


CHAPTER   XV 
Children.    Calcification  of  the  Tissues.    Anemia.     Physiology 

C/ii/dren 

Children  more  easily  penetrated  by  the  X-rays  than  adults    .....  384 
In  cases  suggesting  tuberculous  meningitis.  X-ray  examination  of  value  to  deter- 
mine whether  or  not  tuberculous  foci  exist  in  the  lungs       ....  385 
Same  general  rules  for  making  examination  of  adults  apply  to  children           .         .  385 

Calcification  of  the  Tissues 

Calcification  of  the  tissues     ...........  385 

Aii(F///ia 

Appearances  seen  on  the  fluorescent  screen  in  ansmia  and  pernicious  anasmia       .  388 

Small  hearts  .............  388 

Error  possible  as  to  width  of  heart  by  ordinary  methods        .....  388 

P/iysiology 

Physiology  of  the  voice  and  speech        .........     389 

Effect  of  excessive  exercise  on  the  heart        ........     390 

CHAPTER   XVI 

Therapeutic  Uses  of  the  X-Rays.    Their  Action  on  Bacteria 

Diseases  of  the  skin  : 

Effect  of  X-rays  on  normal  and  abnormal  skin        ......  392 

Mode  of  action  of  X-rays        ..........  393 

Lupus : 

Illustrative  Cases   ............  394 

Susceptibility  of  the  patient    ..........  398 

Cumulative  action  of  the  rays          .........  399 

Protection  of  patient      ...........  399 

Distance  of  the  tube       ...........  401 

Length  and  frequency  of  sittings    .         .         .         ,         .         .         .         .         .401 

Lupus  erythematodes     ............  404 

Syphilis  simulated  by  lupus 406 

Eczema         ..............  407 


TABLE    OF    CONTENTS 


Nasvus  flammeus  or  vasculosus 

Sycosis  and  favus 

Sycosis  non  parasitaria 

Hypertrichosis 

Lymphomata  colli 

Psoriasis 

Acne     . 

Tuberculosis 

Trigeminal  neuralgia 

New  Growths  : 

Carcinoma  of  breast  and  stomach 

External  forms  of  cancer 

Rodent  ulcer 
X-rays  as  an  analgesic 
Articular  Rheumatism  . 

Changes  produced  on  the  skin  by  exposure  to  an 
Cause  of  the  so-called  X-ray  burn 
Effect  of  X-rays  on  bacteria  . 
Effect  of  X-rays  on  developed  colonies 
Effect  of  concentrated  light  on  bacteria 
Effect  of  X-rays  on  animals  inoculated  with  bacteria 


excited  vacuum  tube 


CHAPTER   XVII 

Introduction  to  Surgery 

Surgical  uses  of  the  X-rays   . 

Degree  of  power  needed  in  the  apparatus 

X-ray  photograph  and  fluorescent  screen 

Knowledge  of  normal  bones  and  joints.     Interpretation  of  X 

\'alue  of  negative 

Two  or  more  negatives  made 

Stereoscopic  pictures     . 

Comparison  of  well  and  affected  bone 

Importance  of  two  views 

Importance  of  good  negatives 

Swelling  about  a  fracture  and  swollen  joints 

Bones  and  soft  tissues  .... 


ray  pictures 


CHAPTER   XVIII 


Development  of  the  Skeleton.     Congenital  Malformations. 
Frontal  Cavities.     Muscle 

Development  of  the  skeleton  : 

Epiphyses      ............ 

Epiphyseal  lesions  in  children         ........ 


TABLE    OF   CONTENTS 


Disturbance  of  the  development  of  the  bones  in  cretinism 

Ossification  of  the  cartilage  of  the  larynx 
Congenital  malformations  : 

Deficiency  and  arrested  development  of  bones 

Spina  bifida  ......... 

Frontal  cavities     ......... 

Muscle  .......... 

Myositis  ossificans  ....... 


461 
462 

463 
464 
464 
465 
465 


CHAPTER   XIX 
Fractures  and  Dislocations 

Methods  of  examination : 

Examination  with  fiuorescent  screen       .... 

Examination  with  radiograph  ..... 

Importance  of  photographs  from  two  points  of  view 

Stereoscopic  pictures      ....... 

Errors  to  be  avoided      ....... 

Advantages  of  permeable  splints  and  dressings 
Examination  of  special  bones  of  the  body  illustrated  by  radiographs 

Skull '       .         .        '. 

Spine     ......... 

Shoulder        ........ 

Elbow    ......... 

Lower  end  of  radius,  ulna,  and  wrist 

Supposed  fracture  of  radius  ;  none  found  by  X-rays 

New  and  old  callus  about  a  fracture 

Fracture  of  phalanges  and  metacarpal  bones  liable  to  be  overlooked  w 
X-rays 

Hip 

Thigh    . 

Knee 

Leg  and  ankle 

Absence  of  fracture  indicated  by  X-rays  ;  fracture  by  ordinary  methods 

Advantage  of  comparing  injured  and  uninjured  leg 

Tarsus  ......... 

X-rays  show  true  cause  of  chronic  swelling  of  foot 
Dislocations  ........ 


thout 


468 
468 
469 
469 

471 
471 

475 
475 
481 
485 
488 
488 
490 

491 
493 
495 
499 

501 

C  2  2 

522 

C22 

526 


Methods  of  localization  : 
With  fluorescent  screen 
By  X-ray  photograph     . 


CHAPTER   XX 
Foreign  Bodies 


531 
533 


TABLE   OF   CONTENTS 


Localizers : 

Foreign  bodies 533 

Copper  in  eye 

538 

Bullet  in  head 

539 

Half  dollar  in  oesophagus       .... 

539 

Steel  in  arm  ....... 

540 

Importance  of  two  views.     Needle  in  os  calcis 

543 

Needles          ....... 

545 

Precautions  to  be  taken          .... 

545 

Glass  in  finger       ...... 

550 

Small  pieces  of  metal  visible  in  body 

550 

Whistle  in  pelvis    ...... 

551 

Shot  in  foot 

552 

CH.\PTER    XXI 
Military  Surgery 


Successful  use       .         ... 
Need  of  apparatus  at  base  hospitals 
Use  of  the  X-rays  in  late  war  with  Spain 


553 
553 
554 


CHAPTER   XXII 

DiSE.ASES   OF   THE    BONES   A.\D   OF   THE   JOINTS 

Detection  of  chemical  changes  in  bones  by  the  X-rays         .....  556 

Diseases  of  the  bones  : 

Methods  of  examination     ..........  559 

Periostitis  .............  558 

Osteitis 560 

Spina  ventosa     ............  562 

Regeneration  of  bones  after  operation         .......  562 

Osteomyelitis      ............  564 

Rickets 575 

Coxa  vara  .............  575 

Acromegalia        ............  578 

New  growths       ............  578 

Osteosarcoma     .         .         .         .         .         .         .         .         .         .         .         -579 

Differentiation  of  bony  from  other  tumors 582 

Chondrosarcoma          ...........  583 

Tumor  of  the  left  hand        ..........  585 

Exostosis   .............  586 

Metastatic  carcinoma  .         ..........  587 

Joints  and  cartilages  : 

Methods  of  examination      ..........  587 


TABLE   OF   CONTENTS 


Tuberculosis  of  joints 

Tubercular  osteitis 

Coxitis 

Caries  of  the  spine 

Syphilitic  diseases 

Rheumatoid  arthritis 

Osteo-arthritis    . 
Cartilage : 

Hyaline  cartilage 

Loose  cartilage  . 

Cartilage  affected  by  gout 
Flat  foot 
Bony  and  fibrous  ankylosis 


PAGE 

587 
594 
594 
594 
596 
598 
598 

598 
598 
598 
598 
598 


CHAPTER   XXIII 
Dental  Surgery 

Suitable  apparatus : 

Generator      ........ 

Tube  ;  sharp  definition  ;  proper  degree  of  resistance 

Tube-holder  and  diaphragm 

Screen  .... 
Position  of  patient 
Position  of  plate  or  film 
Main  uses  of  X-rays  in  dentistry 

For  information  in  regard  to 
(a)    Unerupted  teeth 
(/>)    Regulation  of  teeth 

(c)  Pulpless  teeth 

(d)  Alveolar  abscess 

(e)  Fractures  of  roots 
(/)  Root  canals 
(g)    Fluid  in  antrum  . 


603 

603 

604 

605 

606 

606 

606 

607 

607 

611 

612 

613 

613 

. 

613 

CHAPTER   XXIV 


Calculi 


Tests  on  permeability  of  calculi  of  organic  and  inorganic  composition 
Method  of  examination  of  kidneys  and  ureters 
Comparison  of  X-ray  negatives  and  photographs  . 
Comparison  of  X-ray  negative  and  fluorescent  screen    . 
Fenwick's  method  of  examination  of  kidney  outside  of  body 
Method  of  examination  of  bladder         ..... 


615 
617 
620 
620 
621 
621 


TABLE   OF    CONTENTS 


Instrument  for  photographing  calculus  in  bladder 
Cases    .......... 

Gall  stones  ......... 

Absence  of  calculus  not  definitely  determined  b}'  X-rays 
Determination  of  presence  of  calculus   .... 

Conclusions  : 

New  method  of  diagnosis        ..... 

Difficulty  of  diagnosis  by  ordinary  methods    . 

Direct  and  indirect  use  of  X-ravs    .... 


CHAPTER    XXV 

Usefulness  of  X-Rav  Examin.\tion's  to  Life  Insurance  Co.mpanies. 
Medico-Legal  Uses  of  the  X-Rays 

Usefulness  of  X-ray  examinations  to  life  insurance  companies: 

Kidneys,  lungs,  and  heart       .......... 

Determination  of  diseased  condition  the  important  consideration    . 
Medico-legal  uses  of  the  X-rays  : 

Evidence  from  radiographs  in  court         ........ 

Data  needed  on  radiograph    .......... 

Radiographs  interpreted  by  a  surgeon  trained  in  the  use  of  them    . 


APPENDIX 


Origin  of  X-R.ay  Depart.mext  .a.t  the  Boston  City  Hospital. 
System  pursued  in  e.xamining  patients    ..... 

X-Ray  Equipment  : 

Generator ;  static  machine 
Coils      .... 
Portable  apparatus 
Static  machine  and  coils  compared 
Intensifying  screens 
Stereoscopic  tluoroscope 
Tube  and  regulator 

Times  of  exposure  for  X-ray  photographs 
Fluorometer  ..... 
Precautions  for  those  using  the  X-rays 
Method  of  determining  angle  at  which   the  light  passes   through   body  of 
patient  when  examined  by  the  X-rays  ....... 

Head  and  Neck  : 

Tumor  in  head      ............ 

Frontal  sinus  ............ 


TABLE    OF   CONTENTS 


Thorax: 

Emphysema  .  ^       . 

Pneumohydrothorax 

Pleurisy  with  eft'usion     . 

X-rays  by  determining  position  of  heart  show  why  sounds  are  transmitted 

more  distinctly  in  one  place  than  another 
Comparison  between  a  radiographic  and  a  fluoroscopic  examination  in  a  case 

of  dextrocardia 

Abdomen : 

Movement  of  food  through  the  intestines.     Cannon's  experiments  on  cats 
Subdiaphragmatic  abcess       ......... 

Therapeutic  Uses  of  the  X-Rays: 
.■\pparatus      ..... 

Resistance  of  tube  ;  tube  holder    . 
Method  of  treatment :  general  rule 
Exposures  made  by  physicians 
X-ray  dermatitis  ;  acute  and  chronic 
Causes  of  changes  in  the  skin 
Frequency  of  X-ray  burns 
Treatment  for  X-ray  burns 
X-ravs  as  an  analgesic   . 

Illustrative  cases 
X-rays  in  treatment  of  diseases  of  the  skin 

Table  of  skin  diseases  treated  at  Boston  City  Hospital,  not  by  X-rays 
during  a  recent  year    .... 

Diseases  of  the  skin  treated  by  the  X-rays 

1.  Inflammations      .... 

Intertrigo  .... 

Herpes  zoster  .... 
Psoriasis  ..... 
Eczema  ..... 
Acne  vulgaris  and  acne  rosacea 
Prurigo,  pemphigus  foliaceus.  and  lichen  ruber  planus 

2.  Hypertrophies      .... 

Elephantiasis,  verruca,  keratosis 

3.  Atrophies    . 

Growth  of  hair  stimulated  by  the  X 
Alopecia  areata 

4.  Sensory  dermato-neuroses 

Pruritus  ani  and  vulvas 

5.  Parasitic  aftections 

Cutaneous  blastomycosis 

6.  New  growths 

Method  of  treatment  in  cases  of  cancer 
Small  growths    . 
Cancer  of  breast 


TABLE   OF   CONTENTS 


X-rav 


Table  of  150  cases  of  new  growths    . 

Smaller  new  growths,  loi.  table  of 

Illustrative  cases 

New  growths  treated  by  Sequeira. 

and  Merrill,  Pusey,  and  McCaw 

Larger  new  growths.  18,  table  of 

Illustrative  cases 
Cancers  of  breast,  31.  table  of 
Illustrative  cases 
General  remarks 

Operation  before  treatment  by 

operation 
Recurrences 

Comparison  between  treatment  by  X 
cases  of  recurrence  after  operation 
External  new  growths 
Breast  cancer     .... 
Internal  forms  of  cancer    . 

Rollins"  experiments  on  guinea  pigs 
Hypertrophied  scar  tissue 
Lupus  vulgaris 
Lupus  erythematosus 
Leprosy    . 

Mycosis  fungoides     . 
Goitre  with  enlarged  thyroid 
Pulmonary  tuberculosis 
Chronic  tuberculous  peritonitis 
Adenitis         ..... 
Tuberculous  sinuses 
Old  ulcerations      .... 
Hodgkin's  disease 
Disease  of  cornea 

Foreign  Bodies  : 

Localizer  for  determining  foreign  bodies  in  the  eye 
CEsophagus  ........ 

Stomach 


Lancashire,  Johnson 


s;   X 


rays 


and  operation  in 


-ravs  instead  of 


Diseases  of  the  Bones: 

Hip  joint       ......... 

Osteomyelitis         ........ 

Sequestrum  ......... 

Osseous  cyst  ........ 

List  of  Articles  ox  Therapeutic  Uses  of  the  X-Rays 

Index  


LIST    OF    ILLUSTRATIONS 


X-ray  photograph    of  equal  bulks  of  substances  which  represent  the  con 

stituents  of  the  body  in  a  general  way         ..... 
X-ray  photograph  of  two  cups  containing  blood  and  water  respectively 
Front  view  of  static  machine 
End  view  of  static  machine  . 
Detail  of  metal  parts  of  static  machine . 
Side  view  of  static  machine  . 

Diagram  of  static  machine,  tube,  and  adjustable  spark-gap 
Adjustable  multiple  spark-gap 
Medium-sized  static  machine 
Diagram  showing  construction  of  coil    . 
Heinze  interrupter  .... 

Primary  battery,  Ritchie  coil,  Hammer  interrupter  and  tube 
Storage  battery,  Ritchie  coil.  Hammer  interrupter  and  tube 
Small  dynamo.  Ritchie  coil,  Hammer  interrupter  and  tube 
Ritchie  coil,  Wehnelt  interrupter  and  tube 
Heinze  electrolytic  interrupter,  Ritchie  coil  and  tube 
Adjustable  multiple  spark-gap  on  Ritchie  coil 
Adjustable  multiple  spark-gap  for  coil    . 
Portable  apparatus  .... 

Diagram  of  high  frequency  coil 
A.  W.  L.  universal  coil 
Diagram  of  A.  VV.  L.  universal  coil 
Combination  of  storage  battery  and  gravity  cells 
A.  W.  L.  rotary  target  tube  with  movable  target 

A.  W-  L-  rotary  target  tube  with  movable  target  and  internal  diaphragm 
Cooled  target  tube  .... 

Section  of  cooled  target  tube 
A.  W.  L.  tube  for  direct  currents  . 
Details  of  rotary  target 
Faulty  type  of  tube        .... 
Cut  illustrating  formation  of  cathode  stream  and  X-rays 
Double  focus  tube  for  high  frequency  coils 
A.  W.  L.  tube  for  high  frequency  coils  . 
A.  W.  L.  tube  with  cooled  target  . 


5 

7 

9 

II 

12 
13 
15 

16 
18 

19 
21 

23 
23 
24 
24 
25 
25 
26 
27 
28 
29 
31 

33 

34 
34 
36 
36 
36 
37 
37 
38 

39 
40 
40 


XXIV 


LIST   OF    ILLUSTRATIONS 


35- 
36. 
37- 
38. 
39- 

40. 
41. 

42. 

43- 
44. 

45- 
46. 

47- 
48. 
49. 
SO. 

51- 
52. 
53- 

54- 

55- 
56. 

57- 
58. 

59- 
60. 
61. 

62. 

63- 
64. 
65. 
66. 
67. 
68. 
69. 

-JO. 

71- 
72. 

11- 
74- 
75- 
76. 

77- 


th  e 


d  inclination  o 


A.  W.  L.  tube  with  rotary  target 

Tube  with  continuous  metallic  conductor        .... 
Diagram  showing  method  of  determining  resistance  of  tube  . 

Tube  with  regulator 

Diagram   showing  the   eftect   of   the   resistance   of   the  tube   on 

]Mcture  and  the  advantage  of  the  adjustable  multiple  spark-gap 

Tube-holder ' 

Tube-holder  with  tube  in  bo.x         .... 

Tube-holder  with  tube  in  box         .... 

Tube-holder  with  box  open    ..... 

Detail  of  device  for  connecting  tube  with  terminals 
Tube-holder  with  box  closed  .... 

Tube-holder  box  open    ...... 

Tube-holder  box  closed  and  ready  for  use 

Showing  method  of  examining  patient  in  prone  position 

Apparatus  at  Boston  City  Hospital,  static  machine 

A.  VV.  L.  universal  coil  at  hospital 

Tube,  plate,  and  pins     ...... 

X-ray  photograph  of  pins       ..... 

Diagram  showing  effect  of  distance  of  tube  from  object  an 

plate  ......... 

Indirect  plumb-line         ...... 

Showing  method  of  using  indirect  plumb-line 

Showing  method  of  examining  thorax  with  patient  sitting 

Rear  view  of  Fig.  56     ......  . 

Showing  method  of  examining  thorax  with  patient  sitting 
Showing  method  of  examining  thorax  with  large  open  screen 
.Showing  method  of  examining  thorax  with  screen  with  celluloid  cover 
Showing  method  of  drawing  X-ray  outlines  on  chest  while  looking  th 

fluoroscope  ....... 

Diagram  showing  method  of  localization 

Diagram  showing  method  of  localization 

Diagram  showing  method  of  localization 

Diagram  showing  method  of  localization 

X-ray  photograph  of  hyoid  bone  and  part  of  trachea 

X-ray  photograph  of  cervical  vertebrje  . 

X-ray  photograph  of  cervical  vertebrae    . 

Method  of  taking  an  X-ray  photograph  of  fractured  leg 

Method  of  taking  an  X-rav  photograph  of  fractured  hand 

Method  of  photographing  heart  and  lungs 

Method  of  photographing  spine      .... 

Method  of  examining  negative        .... 

Diagram  of  thorax  in  health  ..... 

X-ray  tracing  of  normal  heart  and  diaphragm  lines 
X-ray  photograph  of  thorax  ..... 

Densitometer  ....... 


X-ray 


rough 


LIST   OF    ILLUSTRATIONS 


Photograph  of  diaphragm  lines  traced  on  chest  by  X-rays 
X-ray  tracing  of  normal  thorax     . 
X-ray  photograph  of  tuberculous  lung  . 
Diagram  of  pulmonary  tuberculosis 
X-ray  tracing  of  early  pulmonary  tuberculosis 
X-ray  tracing  of  early  pulmonary  tuberculosis.     Tina  M. 
X-ray  tracing  of  early  pulmonary  tuberculosis.     M.  F. 
X-ray  tracing  of  early  pulmonary  tuberculosis.     M.  G. 
X-ray  tracing  of  early  pulmonary  tuberculosis.     M.  G. 
X-ray  tracing  of  early  pulmonary  tuberculosis.     iVL  G. 
X-ray  tracing  of  M.  G.,  chest  nearly  normal 
X-ray  tracing  of  M.  G.  after  taking  cold 
X-ray  tracing  of  AL  G.  after  return  from  sanitarium 
X-ray  tracing  of  chest  where  physical  signs  indicated  tubercul 
did  not     ....... 

X-ray  tracing  of  pulmonary  tuberculosis.     J.  'SI. 

X-ray  tracing  of  pulmonary  tuberculosis.    J.  H. 

X-ray  tracing  of  acute  pulmonary  tuberculosis.     Sarah  H. 

X-ray  tracing  (second)  of  Sarah  H. 

X-ray  tracing  (third)  of  Sarah  H. 

X-ray  tracing  (fourth)  of  Sarah  H. 

X-ray  tracing  of  pulmonary  tuberculosis.     L.  B.  C. 

X-ray  photograph  of  pneumonic  lung   . 

X-ray  photograph  of  pneumonic  lung   . 

Diagram  of  thorax.     Pneumonia 

X-ray  tracing  of  C.  P.     Pneumonia 

X-ray  photograph  of  thorax  of  C.  P.     . 

X-ray  tracing  of  pneumonia.     E.  R. 

X-ray  tracing  of  pneumonia.     F.  G. 

X-ray  record  of  pneumonia.     B.  AIcL. 

X-ray  record  of  pneumonia.     G.  R. 

X-ray  record  (second)  of  G.  R.    . 

X-ray  record  (third)  of  G.  R. 

X-ray  record  (fourth)  of  G.  R. 

X-ray  tracing  of  Simon  G.     Pneumonia 

X-ray  tracing  (second)  of  Simon  G.     . 

X-ray  tracing  (third)  of  Simon  G. 

X-ray  tracing  (fourth)  of  Simon  G. 

X-ray  tracing  of  Clara  B.     Central  pneumonia 

X-ray  tracing  (second)  of  Clara  B. 

X-ray  tracing  of  pneumonia.     Julia  F. 

X-ray  tracing  (second)  of  Julia  F. 

X-ray  tracing  of  pneumonia.     Essie  L. 

X-ray  tracing  (second)  of  Essie  L. 

X-ray  tracing  of  pneumonia.     Joseph  S. 

Diagram  of  emphysema  of  lungs  . 


but  X-rays 


LIST   OF    ILLUSTRATIONS 


P. 

Mc.AL 

M 

E.  H. 

T. 

R.      . 

23.  X-ray  tracing  of  emphysema  of  lungs.     Patrick  \V. 

24.  X-ray  tracing  (third)  of  Patrick  W 

25.  X-ray  photograph  of  emphysema.     Henry  B. 

26.  X-ray  tracing  of  chest  of  boy  who  had  swallowed  a  walnut  shell 

27.  Diagram  of  pleurisy  with  small  eftusion         .... 

28.  Diagram  of  pleurisy  with  large  et^usion  .... 

29.  X-ray  record  of  pleurisy  with  effusion. 

30.  X-ray  record  of  pleurisy  with  effusion. 

31.  X-ray  record  of  pleurisy  with  effusion. 

32.  X-ray  record  (third)  of  T.  R.  showing  improvement    . 

33.  X-ray  record  (fifth)  of  T.  R.  showing  further  improvement 

34.  X-ray  tracing  of  pleurisy  with  effusion.     C.  D.     . 

35.  X-ray  tracing  of  pleurisy  with  effusion.     J.  L. 

36.  X-ray  record  of  encysted  pleurisy.     W.  T.  . 
27.   X-ray  tracing  of  pleurisy  on  left  side  and  pneumonia  on  left  side  and  at 

right  apex.     D.  M.    . 

38.  X-ray  tracing  (second)  of  D.  M.  showing  improvement 

39.  X-ray  record  of  pleurisy  with  effusion.     Mary  F. 

40.  X-ray  record   (second)   of  Mary  F.     Tuberculosis   and  pleurisy,  the  latte 

diminished        ......... 

41.  X-ray  record  (third)  of  Mary  F.,  still  less  effusion 

42.  X-ray  tracing  of  pleurisy  with  effusion  and  tuberculosis.     John  J 

43.  X-ray  record  of  pleurisy  with  effusion.     Andrew  J.  K. 

44.  X-ray  record  (second)  of  Andrew  J.  K.,  showing  improvement 

45.  X-ray  tracing  of  John  F.     Pleuritic  adhesion 

46.  X-ray  tracing  of  James  A.  W.        ...... 

47.  Diagram  of  pneumothorax  of  left  side  and  tuberculosis  of  right  side 

48.  X-ray  tracing  of  pneumothorax  of  left  side  and  tuberculosis  of  right  side 

Delia  H 

49.  X-ray  tracing  (second)  of  Delia  H. 

50.  X-ray  tracing  (third)  of  Delia  H. 

51.  X-ray  tracing  (fourth)  of  Delia  H. 

52.  Diagram  of  pneumohydrothorax  .... 

53.  X-ray  tracing  of  pneumohydrothorax.     C.  P.  W. 

54.  X-ray  tracing  of  pneumohydrothorax.     Tony  M. 

55.  X-ray  photograph  of  heart  in  full  inspiration 
36.    X-ray  photograph  of  heart  in  quiet  breathing 

57.  Diagram  of  heart  movements        .... 

58.  X-ray  tracing  of  triangle  and  heart  lines        ..... 

59.  X-ray  tracing  showing  faulty  method  of  recording  heart  outlines,  and 

by  percussion.     AL  C.       . 

60.  X-ray  tracing  (second)  of  M.  C.   ....... 

61.  X-ray  tracing  (third).     M.  C.       . 

62.  X-ray  tracing  of,  and  percussion  outline  of.   heart  compared.     Mary  F.    D 

Pleurisy    ............ 

163.    X-ray  tracing  of,  and   percussion  outline  of,   heart   compared.      Harry    M 


LIST   OF   ILLUSTRATIONS 


X-ray  tracing  of,  and  percussion  outline  of,  heart  compared.     John  W.  M 

X-ray  tracing  of,  and  percussion  outline  of.  heart  compared.     Catherine  P 

X-ray   tracing  of,    and   percussion   outline   of,   heart   compared.     Alex.  M 

Pleurisy    .......... 

X-tracing  of,  and  percussion  outline  of,  heart  compared.     C.  D.     Pleurisy 

X-ray  tracing  of  heart.     Paul  S. 

X-ray  tracing  (second)  of  Paul  S.         .         .         .         .         . 

X-ray  tracing  of  thorax.     Michel  F.     Early  tuberculosis 
X-ray  tracing  of  thorax.     Mabel  L.       .         .         .         .         . 

X-ray  tracing  of  thorax.     Mary  I.  ..... 

X-ray  tracing  of  thorax.     D.  F.  W.      ..... 

X-ray  tracing  of  thorax.     Edward  \V.  .... 

X-ray  tracing  of  John  C  showing  heart's  axis  nearly  horizontal 
Diagram  of  John  D.     Aortic  insufficiency     .... 

X-ray  record  of  thorax.     Ella  H.  ..... 

X-ray  record  (third)  of  Ella  H.,  showing  improvement 

Diagram  of  passive  congestion,  or  oedema  of  lungs 

Diagram  of  an  aneurism  of  descending  aorta 

Photograph  of  X-ray  outlines  of  aneurism  drawn  on  chest.     M.  J 

X-ray  tracing  of  aneurism  of  aorta.     E.  H. 

X-ray  tracing  of  aneurism.     C.  S. 

X-ray  tracing  of  aneurism.     E.  M. 

X-ray  tracing  of  aneurism  of  aorta.     James  L.      ... 

X-ray  tracing  of  aneurism  and  heart  compared  with  percussion  lines 

X-ray  tracing  of  aneurism  of  descending  portion  of  aortic  arch.     A.  B 

X-ray  tracing  of  aneurism.     O.  D.         . 

X-ray  tracing  of  aneurism  of  ascending  aorta 

X-ray  tracing  of  new  growth  in  thorax.     Daniel  M. 

X-ray  tracing  of  new  growth  in  thorax.     Daniel  M. 

X-ray  tracing  on  right  side  of  Daniel  M.        . 

X-ray  photograph  of  new  growth.     Daniel  M.       .         .         . 

X-ray  tracing  of  sarcoma  of  lungs.     Jacob  D. 

X-ray  tracing  of  sarcoma  of  lungs.     George  D.     . 

X-ray  tracing  of  interstitial  fibrous  pneumonia.      Richard  S. 

X-ray  tracing  and  diagram.      Martin  F.         .         .  .         . 

X-ray  tracing  of  thorax.      Lymph-adenitis.     M.  C. 

X-ray  tracing  of  thorax.     Carcinomatous  bronchial  glands.     Mrs 

X-ray  tracing  of  gangrene  of  lung.     Mary  C.         .         .  . 

X-ray  tracing  of  stomach  of  child  of  seven  years  of  age,  one  hour  after  eating 

X-ray  tracing  of  stomach  of  James  W.  during  digestion 

X-ray  tracing  of  stomach  (second)  of  James  W.  during  digestion 

X-ray  tracing  of  stomach  (third)  of  James  W.  during  digestion 

X-ray  tracing  of  stomach  (fourth)  of  James  VV.     . 

X-ray  tracing  of  stomach  of  M.  W.  during  digestion     . 

X-ray  tracing  of  stomach  (second)  of  M.  W. 

X-ray  tracing  of  stomach  (third)  of  ]\L  W. 


283 

284 
285 


LIST   OF    ILLUSTRATIONS 


Side 


C. 


209.  X-ray  tracing  of  stomach  (fourth)  of  AL  W.         .... 

210.  X-ray  tracing  of  stomach  (fifth)  of  ^L  W.    ..... 

211.  X-ray  tracing  of  stomach  (sixth)  of.M.  \V.  .... 

212.  X-ray  tracing  of  stomach  (seventh)  of  .^L  W.       .... 

213.  X-ray  tracing  of  thorax  of  B.  B.     Cancer  of  hver 

214.  X-ray  photograph  of  pelvis  .         ....... 

215.  X-ray  photograph  of  pelvis  ........ 

216.  X-ray  photograph  of  calcified  radial  artery    ..... 

217.  X-ray  photograph  of  calcified  pleura  from  autopsy 

218.  Showing  method  of  treating  lupus  by  X-rays         .... 

219.  Photograph  of  boy  with  lupus  before  treatment    .... 

220.  Photograph  of  boy  with  lupus  after  treatment       .... 

221.  Photograph  of  woman  with  lupus  before  treatment 

222.  Photograph  of  woman  with  lupus  after  partial  treatment 

223.  Photograph   of  epidermoid  cancer  of  lip    before    treatment.     Front 

H.  X^ 

224.  Photograph   of  epidermoid   cancer   of  lip    before    treatment. 

H.  X. 

225.  Photograph  of  H.  N.  after  treatment.     Front  view 

226.  Photograph  of  H.  N.  after  treatment.     Side  view 

227.  Photograph  of  epidermoid  cancer  of  eyelid  before  treatment.     J 

228.  Photograph  of  J.  C.  during  treatment  ...... 

229.  Photograph  of  epithelioma  of  lip  before  treatment.     B.  F.     Side  vie 

230.  Photograph  of  B.  F.  before  treatment.     Front  view 

231.  Photograph  of  B.  F.  after  about  six  weeks"  treatment    . 

232.  Photograph  of  B.  F.  about  a  month  later      ..... 

233.  Photograph  of  epidermoid  cancer  of  hand  at  beginning  of  treatment 

234.  Photograph  of  hand  of  D.  K.     Side  view     ..... 

235.  Section  of  carcinoma  of  hand  of  D.  K.  before  treatment 

236.  Photograph  of  hand  of  D.  K.  after  some  treatment 

237.  Section  of  carcinoma  of  hand  of  D.  K.  after  some  treatment 

238.  Section  of  carcinoma  of  hand  of  D.  K.  after  some  treatment 

239.  Photograph  of  rodent  ulcer  of  face  before  treatment.     J.  H. 

240.  Photograph  of  J.  H.  after  treatment     .... 

241.  X-ray  photograph  of  foetus   ...... 

242.  X-ray  photograph  of  epiphysis  of  radius 

243.  X-ray  photograph  of  congenital  malformation  of  hand 

244.  X-ray  photograph  of  congenital  malformation  of  right  thumb 

245.  X-ray  photograph  of  both  bones  of  right  leg 

246.  Modification  of  Wheatstone  stereoscope 

247.  X-ray  photograph  of  bandages,  splints,  etc. 

248.  X-ray  photograph  of  fractured  leg         .... 

249.  X-ray  photograph  of  fracture  of  surgical  neck  of  humeais 

250.  X-ray  photograph  of  fracture  of  surgical  neck  of  humerus 

251.  X-ray  photograph  of  healed  fracture  of  lower  third  of  humerus 

252.  X-ray  photograph  of  fracture  of  lower  end  of  humerus  and  olecranon 


D.  K. 


LIST   OF    ILLUSTRATIONS 


XXIX 


X-ray  photograph  of  fracture  of  olecranon  and  head  of  ulna 
X-ray  photograph  of  fracture  of  ulna     ...... 

X-ray  photograph  of  ununited  fracture  ..... 

X-ray  photograph  of  supposed  fracture  of  radius  .... 

X-ray  photograph  of  fracture  of  left  radius  before  operation.     S.  D. 

X-ray  photograph  of  S.  D.  two  months  after  operation 

X-ray  photograph  of  open  fracture  of  radius.      P'rederick  F.      Antero-pos 

terior  view  ...... 

X-ray  photograph  of  Frederick  F.     Lateral  view 

X-ray  photograph  of  fracture  of  radius 

X-ray  photograph  of  Colles  fracture 

X-ray  photograph  of  fracture  of  left  radius  and  tip  of  styloid  process  of 

Antero-posterior  view.     Gertrude  F.  . 
X-ray  photograph  of  radius  of  Gertrude  F.     Lateral  view 
X-ray  photograph  of  fracture  of  third  metacarpal  bone 
X-ray  photograph  of  fracture  of  phalanx  of  second  linger  of  right  hand 
X-ray  photograph  of  fracture  of  fourth  metacarpal  bone  of  left  hand 
X-ray  photograph  of  fracture  of  fifth  metacarpal  of  hand 
X-ray  photograph  of  fracture  of  thumb         ..... 
X-ray  photograph  of  fracture  of  femur 
X-ray  photograph  of  fracture  of  femur 
X-ray  photograph  of  fractured  patella  . 
X-ray  photograph  of  fractured  patella. 
X-ray  photograph  of  fractured  patella. 
X-ray  photograph  of  fracture  of  tibia. 
X-ray  photograph  of  fracture  of  tibia. 

X-ray  photograph  of  fracture  of  fibula  ..... 

X-ray  photograph  of  fracture  of  both  bones  of  leg.     Antero-posterior 

William  A. 

X-ray  photograph  of  William  A.     Lateral  view    .... 

X-ray   photograph  of  fibrous   fracture  of    fibula.      Antero-posterior 
John  C.     ..........         . 

X-ray  photograph  of  John  C.     Lateral  view  .... 

X-ray  photograph  of  fracture  of  both  bones  of  right  leg.     James  H.  G 
X-ray  photograph  of  fracture  of  tibia  and  longitudinal  split  in  fibula 
X-ray  photograph  of  fracture  of  tibia  and  fibula  . 

X-ray  photograph  of  fracture  of  tibia 

X-ray  photograph  of  uninjured  leg        ..... 
X-ray  photograph  of  fracture  of  tibia  of  boy  six  years  old    . 
X-ray  photograph  of  uninjured  leg  of  boy  six  years  old 
X-ray  photograph  of  fracture  of  both  bones  of  leg  and  callus 
X-ray  photograph  of  fracture  of  both  bones  of  leg 
X-ray  photograph  of  fracture  of  both  bones  of  leg,  due  to  torsion 
X-ray  photograph  of  fracture  of  both  bones  of  leg.  caused  by  blow 
X-ray  photograph  of  fracture  of  tibia  and  fibula  .... 
X-ray  photograph  of  fracture  of  epiphysis    ..... 


Lateral  view . 
Antero-posterior  view 

Front  view 
Side  view 

John  S.      Lateral  view 
John  S.  . 


LIST   OF    ILLUSTRATIONS 


295. 
296. 
297. 

298. 
299. 


301. 
302. 
303- 
304- 

305- 
306. 

307- 
308. 

309- 
310. 

311- 
312. 

313- 
3'4- 
315- 
316. 

317- 
318. 

319- 
320. 
321. 
322. 
323- 
324- 
325- 
326. 

V-1- 


329- 
330- 

331- 

332- 
333- 
334- 
335' 


Antero-posterior  view 
Lateral  view 
Antero-posterior  view 
Lateral  view 


X-rav  photograph  of  injured  foot 

X-ray  photograph  of  uninjured  foot 

X-ray  photograph  of  fracture  of  phalanges  of  great  toe  and  fracture  of  first 

phalanx  of  second  toe       ........ 

X-ray  photograph  of  dislocated  thumb 

X-ray  photograph  of  dislocation  of  both  bones  of  forearm  . 

X-ray  photograph  of  dislocation  and  separation  of  lower  end  of  femur 

Hugh  C 

X-ray  photograph  of  Hugh  C,  taken  nearly  three  months  later 
X-ray  photograph  of  subdislocation  of  metatarsus 
Mackenzie  Davidson  exposer        ...... 

Mackenzie  Davidson  localizer       ...... 

X-ray  photograph  of  half  dollar  in  oesophagus 

X-rav  photograph  of  whistle  in  oesophagus  .... 

X-rav  photograph  of  steel  in  arm.     Antero-posterior  view    . 

X-ray  photograph  of  steel  in  arm.     Lateral  view 

X-ray  photograph  of  needle  in  os  calcis        .... 

X-ray  photograph  of  needle  in  hand     .         .  •  .         . 

X-ray  photograph  of  needle  in  hand. 

X-ray  photograph  of  needle  in  hand. 

X-ray  photograph  of  needle  in  wrist. 

X-ray  photograph  of  needle  in  wrist. 

X-ray  photograph  of  glass  in  finger      ...... 

X-ray  photograph  of  whistle  in  pelvis  ...... 

X-ray  photograph  of  shot  in  foot  ...... 

X-ray  photograph  of  acute  periostitis  of  radius     .... 

X-ray  photograph  of  chronic  periostitis  of  fibula  and  tibia.     Augusta 
X-ray  photograph  of  diseased  hand  of  Augusta  G.       .         .         . 

X-ray  photograph  of  osteitis  of  tibia  and  fibula    .... 

X-ray  photograph  of  osteomyelitis  of  lower  jaw   .... 

X-ray  photograph  of  osteomyelitis  of  tibia.     Alex.  S.     Lateral  view 
X-ray  photograph  of  osteomyelitis.     Alex.  S.     Antero-posterior  view 
X-ray  photograph  of  osteomyelitis.     Mary  P.     Before  operation  . 
X-ray  photograph  of   osteomyelitis.      Mary  P.     After  operation. 

posterior  view  .......... 

X-ray  photograph  of  Marv  P.     Lateral  view  after  operation 
X-ray  photograph  of  osteomvelitis  of  tibia.      H.  T.   S.     Antero 

view  ........... 

X-ray  photograph  of  H.  T.  S.     Lateral  view        .... 

X-ray  photograph  of   osteomyelitis  of  radius.     Delora  A.   S.     Antero 

terior  view         .......... 

X-ray  photograph  of  Delora  A.  S.     Lateral  view 

X-ray  photograph  of  osteomyelitis.     Roy  H.     .Antero-posterior  view 

X-ray  photograph  of  Roy  H.     Lateral  view  .... 

X-ray  photograph  of  rickets  ...... 

X-ray  photograph  of  coxa  vara     ....... 


A 


ntero 


posterior 


-pos 


LIST   OF   ILLUSTRATIONS 


Chondrosarcoma  of 
Antero-posterior  vi( 
Lateral  view  . 


\2,f>.    X-ray  photograph  of  osteosarcoma  of  humerus 
Photograph  of  knee.     Mary  K.    . 

X-ray  photograph  of  knee  of  Mary  K.     Chondrosarcoma  of  femur 
X-ray  photograph  of  hand  of  Mary  K. 
X-ray  photograph  of  hand  of  Mary  K 
Photograph  of  hand  of  A.  B. 
X-ray  photograph  of  hand  of  A.  B.      . 
X-ray  photograph  of  exostosis      ..... 
X-ray  photograph  of  exostosis.     Antero-posterior  view 
X-ray  photograph  of  exostosis.     Lateral  view 
X-ray  photograph  of  tuberculosis  of  ankle    . 
X-ray  photograph  of  tuberculosis  of  foot 
X-ray  photograph  of  tuberculosis  of  foot 
X-ray  photograph  of  tuberculosis  of  hip 
X-ray  photograph  of  diseased  bones  and  joints     . 
X-ray  photograph  of  rheumatoid  arthritis  of  third  finger  joint 
X-ray  photograph  of  loose  cartilage  in  knee  joint 
X-ray  photograph  of  osteo-arthritis  of  great  toe  joint 
X-ray  photograph  of  flat  foot 
Oven  for  heating  tube 

Apparatus  in  position  for  photographing  upper  front  teeth 
Films  for  photographing  teeth 
Metal  film-holder  .... 

X-ray  photograph  of  unerupted  cuspid 
X-ray  photograph  of  unerupted  cuspid 
X-ray  photograph  of  superior  front  teeth 
X-ray  photograph  of  superior  arch 
X-ray  photograph  of  floor  and  antrum 
X-ray  photograph  of  superior  teeth 
X-ray  photograph  of  unerupted  molar 
X-ray  photograph  of  superior  teeth 
X-ray  photograph  of  superior  arch 
X-ray  photograph  of  superior  arch 

X-ray  photograph  of  unerupted  permanent  central  incisor 
X-ray  photograph  of  unerupted  cuspid 
X-ray  photograph  of  superior  arch 
X-ray  photograph  of  superior  arch 
X-ray  photograph  of  unerupted  cuspid 
X-ray  photograph  of  unerupted  cuspid 
X-ray  photograph  of  imbedded  left  central 
X-ray  photograph  of  malplaced  inferior  third  molar 
X-ray  photograph  of  curved  root  of  lateral 
X-ray  photograph  of  bridge  work 
X-ray  photograph  of  abscess  of  upper  jaw 
X-ray  photograph  of  abscess  of  lower  jaw 
X-ray  photograph  of  abscess 


LIST   OF   ILLUSTRATIONS 


382. 

x-ray 

383- 

X-rav 

384- 

X-ray 

385- 

X-ray 

386. 

X-rav 

387- 

X-rav 

388. 

X-rav 

389- 

X-ray 

390- 

Instru 

photograph  of  broken  instrument  in  jaw 
photograph  of  broken  instrument  in  jaw 
photograph  of  broken  lower  incisor     . 
photograph  of  calcuH.  gall  stones,  etc. 
photograpli  of  vesical  calculus    . 
photograph  of  renal  calculi 
photograph  of  renal  calculi,  after  removal 
photograph  of  kidney,  after  removal    . 
ment  for  photographing  calculus  in  bladder 


APPENDIX 


391.  Fluorometer  ............ 

392.  Cut  showing  method  of  determining  angle  at  which  light  is  passing  through 

the  body  ........ 

393.  X-ray  tracing  of  pleurisy  with  ettusion  on  left  side 

394.  X-ray  photograph  of  a  case  of  dextrocardia  . 

395.  X-ray  tracing  of  a  case  of  dextrocardia 

396.  X-ray  tracing  of  case  of  subdiaphragmatic  abscess 

397.  X-rav  apparatus  with  stretcher  and  tube  holder     . 

398.  Cut  showing  method  of  treating  patient  in  a  prone  position 

399.  Photograph  of  psoriasis  of  trunk  after  five  exposures  to  the  X-rays.     A.  B 

400.  Glass  speculum  for  use  in  treating  cancer  of  the  tongue 

401.  Photograph  of  epidermoid  cancer  of  lower   lid   before    treatment   by  the 

X-rays.     Alfred  T.   . 

402.  Photograph  of  Alfred  T.  after  treatment  by  the  X-ra\s 

403.  Photograph   of  epidermoid   carcinoma  of  temple   before   treatment   by  the 

X-rays.     Thomas  H.  G.  ..... 

404.  Photograph  of  Thomas  H.  G.  after  treatment  by  the  X-rays 

405 .  Photograph  of  epithelioma  of  nose  before  treatment  by  the  X-rays.  John  M.  D 

406.  Pliotograph  of  John  M.  D.  after  treatment  by  the  X-rays       ... 

407.  Photograph  of  epithelioma  of  lower  lid  before  treatment  by  the  X-rays.    L.  S 

408.  Photograph  of  L.  S.  after  treatment  by  the  X-rays         .... 

409.  Photograph  of  epithelioma  of  nose  before  treatment  by  the  X-rays.     S.  T 

410.  Photograph  of  S.  T.  after  treatment  by  the  X-rays        .... 

411.  Photograph  of  epithelioma  of  lid  before  treatment  by  the  X-rays.     E.  M 

412.  Photograph  of  E.  M.  after  treatment  by  the  X-rays       .... 

413.  Photograph  of  rodent  ulcer  of  nose  before  treatment  by  the  X-rays.     G.  P 

414.  Photograph  of  G.  P.  after  treatment  by  the  X-rays        .... 

415.  Photograph   of  epithelioma   of  cheek  after  two   exposures   to   the  X-rays 

Mrs.  S ,         .         .     ' 

416.  Photograph  of  Mrs.  S.  after  treatment  by  the  X-rays    ... 

417.  Photograph   of  recurrent  spindle-celled  sarcoma   before   treatment  by   the 

X-rays.     Arthur  B.  ...... 

418.  Photograph  of  Arthur  B.  after  treatment  by  the  X-ravs 


LIST   OF    ILLUSTRATIOxNS  xxxiii 

PAGE 

419.  Photograph  of  epithelioma  of  orbit  before  treatment  by  the  X-rays.     Mrs.  L.  693 

420.  Photograph  of  Mrs.  L.  after  treatment  by  the  X-rays.     Twenty-four  expos- 

ures given         ............  694 

421.  Photograph  of  lymphosarcoma  and  round-celled  sarcoma  before  treatment 

by  the  X-rays.     A.  D 698 

422.  Photograph  of  A.  D.  after  treatment  by  the  X-rays.     Still  under  treatment  699 

423.  Photograph  of  carcinoma  before  treatment  by  the  X-rays.     Dennis  R.          .  701 

424.  Photograph  of  carcinoma  of  breast  before  treatment  by  the  X-rays.  Mrs.  B.  703 

425.  Photograph  of  Mrs.  B.  during  treatment  by  the  X-rays          ....  704 

426.  Photograph  of  carcinoma  of  breast  before  treatment  by  the  X-rays.     Mrs.  D.  705 

427.  Photograph  of  Mrs.  D.  after  treatment  by  the  X-rays.     Still  under  treatment  706 

428.  Photograph  of  cancer  of  breast  before  treatment  by  the  X-rays.     Mrs.  A.    .  707 


THE    ROENTGEN    RAYS 
IN     MEDICINE    AND    SURGERY 


THE  ROENTGEN  RAYS  IN  MEDICINE  AND 

SURGERY 

CHAPTER    I 

NATURE    AND    PROPERTIES    OF   THE   X-RAYS 

The  discovery  by  Professor  Roentgen,  in  1895,  that  in  the  space 
around  certain  vacuum  tubes  through  which  an  electric  discharge  was 
passing  there  was  present  a  form  of  radiation  by  means  of  which  the 
bones  of  the  hands  could  be  seen,  has  provided  a  new  method  in 
diagnosis,  both  for  the  physician  and  the  surgeon,  and  a  new  thera- 
peutic agent.      To  this  radiation  the  discoverer  gave  the  name  of  X-rays. 

Origin  and  Nature  of  the  X-Rays.  —  The  X-rays  are  generated  by 
the  cathode  rays,  and  proceed  in  all  directions  from  the  solid  object 
struck  by  the  latter  (see  Chapter  II,  Fig  31).  Various  theories  are 
entertained  as  to  the  nature  of  the  X-rays,  but  the  balance  of  opinion  ^ 
seems  to  be  in  favor  of  their  being  some  form  of  transverse  ethereal 
vibration.  Stokes^  considers  that  the  X-rays,  the  Becquerel  rays,  and 
the  light  rays  form  a  series,  at  one  end  of  which  stand  the  X-rays  and 
at  the  other  the  light  rays  :  the  X-rays  being  a  succession  of  irregular 
independent  impulses ;  the  Becquerel  rays  still  irregular,  but  to  a  less 
degree  than  the  X-rays ;  and  the  light  rays  a  succession  of  orderly 
disturbances  of  the  ether. 

Properties  Common  to  the  X-Rays  and  to  Light.  —  Both  the  X-rays 
and  light  rays  produce  shadows,  cause  fluorescence,  and  have  a  chemical 
action  on  a  photographic  film. 

Properties  in  which  the  X-Rays  appear  to  differ  from  Light.  —  Certain 
properties  of  light  have  been  claimed  for  the  X-rays,  such  as  polariza- 
tion,   refraction,    and    diffraction ;    but    Roentgen,    in    the    experiment 

1  "  Radiation,"  by  H.  H.  F.  Hyndman. 

"^  "On  the  Nature  of  the  Roentgen  Rays,"  by  G.  G.  Stokes;   printed  in  "  Roentgen  Rays,"  a 
book  edited  by  G.  F.  Barker  (Harper  &  Bros.,  1899). 
B  I 


2  THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

described  in  his  first  Communication, ^  did  not  succeed  in  polarizing  them, 
nor  in  refracting  or  regularly  reflecting  them  to  any  appreciable  extent. 
Several  observers  have  stated  that  they  have  obtained  diffraction  bands, 
but  Hyndman^  considers  that  no  satisfactory  demonstration  of  the 
existence  or  non-existence  of  these  phenomena  has  been  given.  The 
shadows  cast  by  the  X-rays  are  sharper  than  those  of  light,  when  the 
source  of  X-rays  is  sufficiently  narrow,  and  the  absence  of  diffraction, 
would  account  rationally  for  this  fact. 

Property  of  the  X-Rays  of  Peculiar  Value.  —  The  X-rays  have  the 
power  of  penetrating  in  different  degrees  certain  substances  which  are 
opaque  to  light,  and  it  is  this  property  which  gives  them  their  pecuhar 
value.  For  instance,  flesh  is  fairly  transparent  to  the  X-rays,  as  are 
also  wood,  leather,  paper,  and  most  fibrous  materials ;  bone  is  less 
permeable  by  them,  while  most  metals  and  their  compounds  absorb ! 
them.  Thus,  if,  in  a  dark  room,  the  hand  is  placed  between  the  vacuum 
tube  and  a  fluorescent  screen,  a  shadow  of  the  hand  will  be  seen  on 
the  screen,  the  bones  being  sharply  marked  and  the  flesh  showing  but 
faintly  ;  or  if  a  block  of  soft  wood  containing  a  nail  take  the  place  of  the 
hand,  the  nail  will  show  clearly,  and  the  wood  scarcely  at  all.  If  the  pho- 
tographic plate  is  used  instead  of  the  screen,  similar  results  will  follow. 

Law  of  Absorption.  —  The  law  of  absorption  of  the  X-rays  has  not 
been  fully  investigated.  Roentgen,  in  his  first  Communication,  states 
that  experiments  indicate  that  the  transparency  of  different  substances 
of  equal  thickness  is  essentially  dependent  upon  their  density.  Further 
experiments  show  that  the  transparency  of  different  metals  is  not  equal 
even  when  the  product  of  the  thickness  and  density  is  the  same,  the 
transparency  increasing  far  more  rapidly  than  this  product  decreases. 
But  for  present  purposes  the  law  of  absorption  is  nearly  enough  as 
follows  :  The  percentage  of  the  rays  absorbed  by  equal  thicknesses  of 
different  substances  is  not  far  from  proportional  to  their  specific 
gravities  or  densities.  The  percentage  absorbed  by  layers  of  the  same 
substance,  but  of  different  thicknesses,  increases  with  the  thickness,  but 
less  rapidly  than  in  direct  proportion  to  it,  and  the  effect  of  thickness 
increases  far  more  rapidly  in  the  more  opaque  than  in  the  less  opaque 
materials ;  for  example,  more  rapidly  in  bone  than  in  flesh. 

Atomic  Weight. — A  glance  at  this  subject  from  a  chemical  stand- 
point will  be  helpful.     The  density  of  a  substance  is  largely  dependent 

1  "  Roentgen  Rays,"  edited  by  G.  F.  Barker  (Harper  &  Bros.,  1899). 

2  "  Radiation,"  by  H.  H.  F.  Hyndman. 


NATURE   AND    PROPERTIES   OF   THE   X-RAYS 


upon  its  atomic  weight,  and  as  the  human  body  is  what  concerns  us 
here,  the  following  table,  which  gives  the  atomic  weight  of  those 
elements  which  enter  chiefly  into  its  structure,  is  suggestive :  — 

TABLE    I 


Element. 


Hydrogen 
Carbon  . 
j  Nitrogen 
I  Oxygen  . 
(Fluorine . 
I  Sodium  . 
Magnesium 


Atomic 
Weight. 


I 

12 

M 
i6 

19 
23 
24 


Element. 


Phosphorus 

Sulphur 

Chlorine 

Potassium 

Calcium 

Iron  (to  small  amount  only) 


Atomic 
Weight. 


31 

32 

35-5 

39 

40 

56 


It  may  be  noted  that  although  the  atomic  weight  of  the  known  ele- 
ments ranges  from  i  to  239.4  (uranium),  yet  in  normal  constituents  of 
the  human  body  we  have  to  deal  with  elements  ranging  only  from  i  to 
56,  and  in  effect  only  from  i  to  40,  if  we  disregard  iron,  which  enters 
only  in  minute  quantities. 

Absorptive  Power  of  Fat,  Muscles,  Bones,  etc.,  of  the  Body.  —  Water  is 
the  chief  constituent  of  the  soft  tissues  of  the  body,  and  enters  into 
the  composition  of  all  parts  of  it,  and  this  liquid  contains,  as  its  heaviest 
element,  oxygen,  with  an  atomic  weight  of  16.  Fats  are  lighter  than 
water  and  more  readily  traversed  by  the  rays.  Muscle,  and  the  various 
liquids  of  the  body  in  addition  to  water,  are  made  up  of  organic  sub- 
stances consisting  largely  of  compounds  of  carbon  (atomic  weight  12), 
oxygen  (16),  nitrogen  (14),  and  hydrogen  (i).  They  contain  no  heavier 
element,  except  in  minute  quantities,  than  does  water,  and  thus  (except 
in  so  far  as  their  molecules  may  be  more  or  less  closely  grouped)  they 
should  have  an  absorptive  power  differing  little  from  that  of  water ; 
and  such  is  the  observed  fact.  On  the  other  hand,  bone,  although 
largely  made  up  of  water  and  organic  substances  similar  to  the  other 
tissues,  is  composed  also  of  a  considerable  proportion  of  triphosphate 
of  calcium  ;  it  thus  contains  the  heavier  elements,  phosphorus  (31)  and 
calcium  (40).  We  should  therefore  expect  that  it  would  show,  as  it 
does,  a  markedly  greater  absorptive  power  than  the  other  tissues. 
Similarly,  as  uric  acid  is  a  compound  containing  only  carbon,  hydrogen, 


4  THE    ROENTGEN    RAYS    IN    MEDICINE    AND   SURGERY 

and  oxygen,  calculi  composed  of  this  substance  would  have  a  less 
absorptive  power  than  would  calculi  consisting  of  oxalate  of  calcium, 
which  is  made  up  largely  of  calcium  (atomic  weight  40),  at  least, 
unless  the  molecular  grouping  was  very  different  in  the  two  cases. 
Observation  shows,  as  will  be  seen  in  the  chapter  on  Calculi,  that 
this  contrast  in  the  respective  absorptive  powers  of  these  two  kinds 
of  calculi  obtains. 

Absorptive  Power  of  Air  and  Gases.  —  Air  and  other  gases,  owing  to 
their  small  densities  as  compared  with  liquids  and  solids,  may  be 
regarded  for  the  present  purpose  as  wholly  transparent  to  the  X-rays. 
The  importance  of  this  contrast  will  be  evident,  especially  when  we 
come  to  the  study  of  thoracic  diseases,  and  to  diseases  of  the  stomach 
and  abdomen.  The  difference  in  permeability  of  air  and  water  is  par- 
ticularly worthy  of  notice,  as  air  makes  up  a  certain  bulk  of  the  body, 
a  large  part  of  the  chest  is  filled  with  it,  and  water  is  one  of  its  most 
important  factors,  as  already  noted. 

The  picture  of  the  body,  then,  seen  on  the  screen  or  photographic 
plate,  is  due  to  the  fact  that  substances  of  different  chemical  composi- 
.tion,  molecular  grouping,  and  thickness  absorb  different  amounts  of 
the  rays.  For  instance,  two  muscles  lying  side  by  side  may  be  dis- 
tinguished, probably  through  difference  in  bulk,  but  we  should  not 
expect  to  distinguish  in  the  radiograph  the  outlines  of  two  tissues  of 
similar  composition  and  thickness,  if  they  are  contiguous.  If  a  layer 
of  less  dense  substance,  such  as  adipose  tissue,  separates  them,  how- 
ever, we  get  by  contrast  the  outline  of  the  muscle  on  both  sides  of  the 
fat.  The  outlines  of  the  arteries,  such  as  the  brachial,  radial,  and  ulnar 
arteries,  show,  partly,  I  think,  because  their  walls  are  more  transparent 
to  the  X-rays  than  the  blood  they  contain  and  than  the  adjacent  tissues. 
In  radiographs  which  I  took  in  1896,  of  healthy  individuals,  both  young 
and  middle-aged,  I  distinguished  bones,  arteries,  muscle,  skin,  tendons, 
and  adipose  tissue.  When  making  an  examination  of  the  body,  there- 
fore, the  respective  chemical  composition  of  the  liquids  and  solids  com- 
posing it  in  health  and  disease,  as  well  as  the  thickness  of  the  parts, 
must  be  borne  in  mind  ;  likewise  the  fact  that  air  and  gases  offer 
practically  no  obstacle  to  the  rays. 

The  following  radiograph,  which  I  took  in  1896,  in  order  to  gain 
some  conception  of  the  permeability  of  the  various  constituents  of  the 
body  by  the  X-rays,  is  pertinent  here.  The  substances  radiographed 
were  enclosed  in  small  pasteboard  boxes. 


NATURE    AND    PROPERTIES    OF    THE    X-RAYS 


Fig.  I.     Radiograph  of  equal  bulks  of  various  buhst.iiuis  uhidi  represent   the   constituents  of  the 

body  in  a  general  way. 

WEIGHT 

5.    Gelatin 4.    grammes. 


WEIGHT 

1.  Carbonate  of  magnesium  .     .  1.6  grammes. 

2.  Stearic  acid 3.8  " 

3.  Oleic  acid 3.5 

4.  Palmitic  acid 4.4  " 

9.   Glycerine 4     grammes. 

10.  Water 14 

11.  Oxalic  acid 12.2 

12.  Phosphate  of  sodium     .     .     .  10.6 

16.  Chloride  of  sodium  ....  8.5  grammes. 

17.  Sulphur 13.9 

18.  Chloride  of  potassium  .     .     .  lo.i  " 


6.  Dried  egg  albumen    ....  6.4 

7.  Carbonate  of  sodium     ...  5.9 

8.  Milk  sugar 11.7 

13.  Phosphate  of  calcium     .     .     .  2.6  grammes. 

14.  Sulphate  of  sodium  ....  10.8  " 

15.  Magnesium  ammonium  phos- 

phate      12.5  " 


19.  Carbonate  of  calcium 

20.  Fluoride  of  calcium   . 


•  15-3  grammes. 
.  11.7 


This  experiment  suggests  how  we  may  recognize  some  changes  in 
chemical  composition  made  in  the  body  by  pathological  processes. 
The  ability  to  do  this  without  beaker  or  reagent,  or  without  disturbing 
the  vital  processes,  is  a  step  in  the  application  of  chemistry  and  physics 
to  practical  medicine  which  hints  at  what  the  future  may  have  in  store 
for  us.^ 

1  Medical  and  Surgical  Report,  Boston  City  Hospital,  January,  1897,  " -'^  Study  of  the 
Adaptation  of  the  X-Rays  to  Medical  Practice,"  by  Francis  H.  Williams,  M.D. 


6  THE   ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

Experiments  continued.  —  At  this  same  time   I   also  made  the  fol- ' 
lowing    series    of     experiments    to    determine    whether     or    not    the ! 
different    fluids    found    in    the    body  in    health   and    disease    could    be  i 
distinguished    by   X-ray   examinations,    using  water    as   a    standard   of 
comparison  :  — 

A  vulcanite  cup  8  centimetres  deep  was  filled  with  water,  and 
beside  it  was  placed  a  similar  cup  filled  with  pleuritic  fluid.  The 
fluorescent  screen  was  put  over  these  two  cups,  and  the  shadows  cast 
by  them  were  compared.  So  far  as  I  could  tell,  there  was  no  appre- 
ciable difference  between  the  two.  I  then  poured  out  about  one-fifth  of 
the  pleuritic  fluid,  and  compared  the  remaining  quantity  with  a  cup 
filled  with  water,  and  it  could  be  easily  seen  that  the  cup  containing  the 
pleuritic  fluid  cast  much  less  shadow  on  the  fluorescent  screen  than 
the  cup  filled  with  water.  While  I  watched  the  shadows  of  both  fluids, 
the  cup  containing  the  pleuritic  fluid  was  gradually  filled  to  the  brim, 
and  when  it  was  so  filled,  the  shadow  of  the  two  cups  was  practically 
the  same.  I  then  chose  other  fluids,  and  compared  them  with  the  same 
volume  of  water,  and  found  there  was  no  marked  difference  between 
the  fluid  from  hydrocele,  ascitic  fluid,  or  pus,  as  compared  with  the 
water.     See  also  chapter  on  Pleurisy,  page  205. 

Opacity  of  Blood  to  X-Rays  compared  with  that  of  Water.  —  It  has 
been  suggested  that  blood  may  be  more  opaque  to  the  rays  than  other 
portions  of  the  body  on  account  of  the  iron  it  contains ;  but  as  the 
amount  of  iron  is  only  about  one  two-thousandth  of  the  weight  of  the 
blood,  this  would  not  make  any  great  difference  in  the  shadow  cast,  as 
compared  with  that  cast  by  an  equal  volume  of  water,  for  the  atomic 
weight  of  iron  is  not  very  great  (56).  Moreover,  the  specific  gravity 
of  blood  is  1.055,  which  is  only  slightly  greater  than  that  of  water; 
so  there  is  no  reason  to  suppose  that  blood  would  cast  a  much  greater 
shadow  than  the  same  volume  of  water. 

Test.  —  To  test  this  point  I  took  two  vulcanite  cups  and  filled  one  with 
water  and  the  other  with  blood  to  the  depth  of  8  centimetres,  and  ex- 
posed them  at  the  same  time  on  the  same  photographic  plate.  In  order 
to  eliminate  any  source  of  error  that  might  arise  from  a  possible  differ- 
ence in  the  thickness  of  the  cups,  I  repeated  the  experiment,  putting 
blood  into  the  cup  that  had  previously  held  the  water,  and  water  into 
the  cup  that  had  contained  the  blood.  Both  experiments  gave  similar 
results.  The  shadow  cast  by  the  cup  containing  even  so  great  a  thick- 
ness of  blood  as  8  centimetres  was  but  little  darker  than  that  cast  by  the 


NATURE    AND    PROPERTIES   OF   THE    X-RAYS  7 

cup  holding  an  equal  thickness  of  water,  and  the  outline  of  the  bottom 
of  the  first  cup  was  less  sharply  defined. 

Enough  has  been  said  to  show  that  the  chemical  composition  of  sub- 
stances may  furnish  a  most  important  clew  in  regard  to  their  respective 
l)()wer  of  absorbing  the  X-rays,  and  the  question  need  not  be  further 
dwelt  upon  here.     The  details  of  the  subject  will  have  a  greater  interest 


Fig.  2.     Cut  made  from  a  radiograph  of  two  similar  vulcanite  cups.      The  one  containing  water, 
the  other  blood,    in  equal  amounts ;  the  cup  holding  the  blood  has  a  metal  ring  beside  it. 


in  the  future,  as  now  the  profession  is  naturally  more  interested  in  the 
well-marked  distinctions  which  are  observed,  rather  than  the  finer  ones 
that  are  more  difficult  to  obtain.  But  it  is  desirable  to  call  attention  to 
the  surprisingly  slight  differences  in  chemical  composition  that  may  be 
differentiated  by  radiographs,  and  to  point  out  to  all  who  are  making  a 
study  of  the  application  of  the  X-rays  to  medicine  that  the  question  of 
chemical  composition  is  an  important  one  to  bear  in  mind  ;  the  X-rays 
give  us  something  more  than  evidence  of  physical  change. 


CHAPTER    II 

X-RAY    EQUIPMENT 

The  chief  parts  of  an  X-ray  outfit  are  a  static  machine,  or  an  induction 
coil;  the  vacuum  tube  with  its  supporting  apparatus;  the  fluorescent 
screen  or  fluoroscope ;  and  the  photographic  plate. 

The  X-rays  are  produced  in  the  vacuum  tube,  and  this  tube  may  be 
excited  by 

1.  Static  Machine ;  the  two  types  of  which  are 

a.  Influence  Machine. 

Forms  of  :   Holtz, 

Toepler-Holtz, 

Voss, 

Wimshurst, 

b.  Plante  Rheostatic. 

Form  of  :    Thomson  Dynamo  Static. 

2.  Induction  Coil ;  the  two  types  of  which  are 

a.  Ordinary  Page,  or  Ruhmkorff,  coil. 

b.  Tesla,  or  high  frequency  coil. 

Form  of  :    Thomson  coil. 

1 .  Static  Machine.  —  The  static  machine  may  be  driven  by  hand,  or  by 
any  form  of  motor  such  as  an  electric  or  water  motor,  or  a  gas  engine ; 
and  may  be  self-exciting  or  be  excited  by  a  small  Toepler-Holtz  or 
Wimshurst  machine. 

2.  Induction  Coil.  —  The  electric  current  for  the  induction  coil  may  be 
obtained  from 

a.  Primary  battery  (low  voltage). 

b.  Storage  battery  (low  voltage) : 

1 .  Charged  by  gravity  cells ; 

2.  Charged  from  street  main. 

c.  A  dynamo  which  generates  a  continuous  or  alternating  current 

of  either  high  or  low  voltage. 

d.  The   street  main   (high   voltage) ;    current    continuous    or  alter- 

nating. 

8 


X-RAY    EQUIPMENT 


Static  Machine 

In  discussing  this  type  of  machine  I  will  describe  the  one  which  I  had 
made  and  have  used  in  my  work  at  the  Boston  City  Hospital.  In  de- 
signing it  I  studied  simplicity  and  stability. 


lO       THE    ROENTGEN    RAYS   IN    MEDICINE    AND   SURGERY 

My  machine  is  of  the  Holtz  form  and  has  four  revolving  plate-glass 
plates  183  centimetres  (6  feet)  iru  diameter,  and  four  fixed  plate-glass 
plates  193  centimetres (6  feet  4  inches)  in  diameter.  These  eight  plates 
weigh  about  1000  pounds.  The  plates  of  a  static  machine  may  be 
made  of  glass,  hard  rubber,  or  mica,  but  glass  is  the  best  material. 

The  machine,  for  the  purpose  of  insulation,  rests  on  eight  or  ten  glass 
blocks  15  X  20  centimetres  and  3  centimetres  or  more  thick,  so  placed 
as  to  bear  its  weight  most  advantageously. 

It  is  run  by  a  one  horse-power  electric  motor. 

When  a  static  machine  is  properly  constructed  it  never  reverses  while 
in  action. 

The  static  machine  is  given  its  initial  charge  by  an  auxiliary 
machine  of  the  Wimshurst  type  with  plates  40.5  centimetres  (16 
inches)  in  diameter.  When  it  is  desired  to  start  the  large  machine,  one 
pole  of  the  exciter  is  connected  with  one  terminal  of  the  large  machine, 
and  the  other  pole  with  an  armature  brush  on  the  opposite  side  of  the 
large  machine. 

In  order  to  bring,  the  terminals  conveniently  near  each  other 
the  terminal  on  the  right  (Fig.  3)  is  extended  by  a  brass  rod  to  a 
brass  ball  (hung  on  a  wooden  rod)  near  the  middle  of  the  machine. 
To  shut  off  the  light  in  the  tube  it  is  only  necessary  to  short-circuit  the 
machine  by  connecting  the  terminals.  This  is  readily  done  by  lowering 
a  brass  rod  so  that  it  rests  across  them.  This  rod  is  shown  in  Fig.  3 
and  also  at  the  upper  part  of  Fig.  8,  and  is  controlled  by  a  cord  which 
hangs  near  the  patient. 

All  the  brass  and  iron  work  of  the  machine  has  had  two  or  three 
coats  of  varnish  to  protect  it  from  corrosion. 

The  machine  is  very  durable,  as  it  is  run  at  slow  speed,  the  bearing 
surfaces  of  the  shaft  are  amply  large,  and  there  is  no  vibration. 

It  is  provided  with  condensers  (see  Fig.  3),  the  object  of  which  is 
to  regulate  the  size  of  the  electric  discharges,  but  I  have  not  found 
it  necessary  to  use  them. 

The  tubes  excited  by  it  are  not  used  up  so  quickly  as  by  a  coil. 

The  working  drawings  show  the  design  of  the  machine  sufficiently 
well,  but  it  may  be  desirable  to  direct  attention  to  one  or  two  points. 

Method  of  holding  Plates.  —  As  the  revolving  plates  are  heavy,  it  is 
necessary  to  have  them  firmly  supported.  Each  pair  of  plates  is  held 
on  the  shaft  between  two  iron  collars  about  30  centimetres  in  diam- 
eter, one  collar  of  each  pair  being  turned  true  upon  the  shaft.     On 


Fig.  4.     End  view  of  static  machine.     Cut  also  shows  some  details  of  shaft  and  attachment  of  plates. 


12       THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

either  side  of  each  plate  are  two  washers  about  30  centimetres  in  diam- 
eter ;  the  one  in  direct  contact  with  the  plate  is  made  of  paper,  and  the 
other  is  made  of  sheet  rubber  i  millimetre  in  thickness.  The  rubber 
washer  gives  elasticity,  and  the  paper  prevents  the  rubber  from  sticking 
to  the  metal  or  the  glass.  Each  pair  of  revolving  plates  is  separated 
by  a  disk,  to  give  room  for  the  stationary  plates.     The  second  collar 


Fig.  5.     Detail  of  metal  parts  of  static  machine. 

of  each  pair  is  pressed  up  against  the  plates  in  a  direction  parallel  to 
the  axis  of  the  shaft  by  means  of  nuts  threaded  on  the  shaft,  the 
amount  of  pressure  being  determined  by  the  nuts.  The  plates,  there- 
fore, are  held  in  position  between  the  metal  collars  by  pressure,  which 
acts  in  a  direction  parallel  to  the  shaft. 

One  side  of  the  plate  is  always  thicker  than  the  other;  therefore, 


X-RAY   EQUIPMENT 


13 


when  the  plates  are  put  on  they  must  be  turned  on  the  shaft  until  the 
point  is  found  where  the  two  sides  balance  each  other.  If  this  method 
is  pursued  before  the  plates  are  secured  tightly  in  place,  they  will  have 
no  tendency  to  come  to  rest  at  one  point  rather  than  another,  and  the 
best  conditions  for  speed  and  steadiness  will  be  procured. 


Fig.  6.     Side  view  of  static  machine.      Revolving  plate  183  centimetres  (6  feet)  in  diameter,  station- 
ary plate  193  centimetres  (6  feet  4  inches)  in  diameter. 


The  stationary  plates  are  supported  at  the  bottom  on  pieces  of  wood, 
which  should  rest  on  glass  to  insure  good  insulation.  The  grain  of 
the  wood  should  run  at  right  angles  to  the  plates  and  not  parallel  with 
them,  because  if  the  piece  of  wood  should  shrink  it  would  become 
narrower  and  thus  change  the  position  of  the  plates  after  they  had  been 
adjusted.  The  plates  are  held  at  the  top  by  means  of  clamps,  threaded 
on  a  transverse  rod,  both  of  which  are  clearly  shown  in  Fig.  4. 


14       THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Speed  Controller. — The  speed  of  the  plates  may  be  varied  from  50 
to  250  revolutions  per  minute  by  means  of  the  speed  controller,  which 
determines  the  speed  of  the  motor,  and  thus  a  greater  or  less  amount  of 
energy  may  be  obtained. 

Leakage  of  Electricity.  —  During  damp  weather  the  leakage  of  the 
electricity  from  the  static  machine  is  greater,  and  a  smaller  amount  is 
generated,  than  in  dry  weather ;  therefore,  the  machine  must  be  large 
enough  to  give  out  a  sufficient  amount  of  electricity  even  when  the  air 
is  moist,  otherwise  the  practitioner  is  at  the  mercy  of  atmospheric  con- 
ditions. A  simple  way  of  ascertaining  the  amount  of  electricity  avail- 
able for  use  is  to  look  at  the  brush  discharge  above  the  collecting 
combs ;  when  this  is  wide  the  amount  is  greater  than  when  it  is 
narrow. 

Precautions  against  Moisture. —  i.  Case.  If  the  plates  are  kept 
warm  and  dry  they  can  be  depended  upon  to  do  good  work,  no  matter 
what  the  weather  may  be.  Therefore,  the  machine  must  be  provided 
with  a  case.  The  case  of  my  machine  is  244  centimetres  long,  228 
centimetres  high,  and  90  centimetres  wide.  A  case  should  be  of  this 
size,  at  least,  for  plates  of  the  dimensions  described.  The  shaft  of  my 
machine  might  well  be  5  centimetres  or  more  longer  than  that  shown 
in  the  drawing,  so  that  if  desired  the  case  could  be  put  a  little  farther 
from  the  machine,  as  by  this  means  the  latter  could  be  surrounded  by 
a  thicker  layer  of  air,  and  therefore  the  leakage  of  electricity  would  be 
diminished.  The  case  is  made  of  pine  doors,  that  can  be  ordered  at 
a  factory,  of  any  size  desired.  These  doors  make  an  inexpensive  and 
good  case.  The  interior  and  exterior  of  the  case  is  varnished  to  give  it 
a  surface  that  will  not  absorb  or  give  out  moisture. 

2.    Removal  of  Dampness  frotn  Plates.  —  Some  method,  also,  must  be 
adopted  for  removing  the  dampness  from  the  plates.     There  are  various 
ways  of  accomplishing  this  object.     Chloride  of  calcium,  for  instance,    , 
and  other  forms  of  drying  material  may  be  used,  placed  in  a  dish  inside   ( 
the  case,  but  I  have  found  them  insufficient  in  themselves  to  take  the 
moisture  from  the  plates ;  moreover,  if  chloride  of  calcium  is  employed, 
there  is  the  risk  that  fine  particles  of  it  will  fall  upon  the  plates  and 
thus  coat  them  with  a  covering  that  absorbs  moisture.      It  is  evident, 
therefore,    that    this    method    of    getting    rid    of    the    moisture    is    not    1 
altogether  satisfactory.     The  most  convenient  and  efficient  method  is    f 
the    use    of    some    form    of    heater,   such   as   an   electric   heater.      The 
heaters,  one  placed  at  either  end  of  the  case,  warm  the  air  in  the  case, 


X-RAY    EQUIPMENT 


15 


the  plates  themselves  then  become  warm,  and  the  moisture  is  driven 
from  their  surface. 

3.  Cleaning  Plates.  —  The  plates  should  be  cleaned  at  regular  inter- 
vals, in  order  to  lessen  the  leakage.  Whiting  and  alcohol  may  be 
used  for  this  purpose  in  the  same  way  as  for  a  plate-glass  window. 
I  have  found  that  glass  plates  that  have  been  covered  with  some  prepa- 
ration, such  as  shellac,  are  not  so  satisfactory  as  those  without  coating, 
as  the  former  cannot  be  kept  perfectly  clean. 

4.  Place  of  Machijic.  —  The  machine  should  be  in  a  dry,  warm  room  ; 
mine  is  in  a  basement  room,  the  floor  of  which  is  90  centimetres  below 


Fig.  7.     Diagram  of  static  machine  and  tube.     Adjustable  spark-gap  at  A. 

the  surface  of  the  ground  and  less  than  that  distance  above  high-water 
mark.  Sea-going  vessels  come  to  wharves  within  150  metres  of  the 
room.  But  although  the  situation  is  as  unfavorable  as  possible,  the 
machine  is  in  daily  use  throughout  the  year.  Since  these  lines  were 
written  the  room  has  been  divided  crosswise  into  two  rooms  by  a 
board  partition.  In  the  one  in  which  the  static  machine  and  motor 
stand  a  radiator  has  been  placed,  which  keeps  the  machine  warm  and 
dry  and  yet  does  not  overheat  the  other  room,  in  which  the  patients  are 
examined  and  which  contains  the  stretcher,  tube,  and  other  appliances. 


l6       THE   ROENTGEN   RAYS   IN    MEDICINE   AND   SURGERY 

In  the  partition  there  are  two  plates  of  glass,  near  the  centre  of  each 
of  which  is  a  small  hole  through  which  the  wires  pass  from  the  static 
machine  to  the  X-ray  tube. 

Adjustable  Spark-gap.  —  The  spark-gap  in  series  with  the  tube  is 
the  air  space  through  which  the  current  must  leap  before  reaching  the 
tube.  (See  A,  Fig.  7.)  In  all  forms  of  X-ray  apparatus  some  means 
is  necessary  for  varying  the  amount  of  light,  and  this  variation  may  be 


Fig.  8.     Adjustable  multiple  spaik-ga; 


accomplished  in  part  by  means  of  a  spark-gap.  The  spark-gap  is  also 
essential  because  it  enables  the  practitioner  to  use  tubes  of  lower 
resistance  than  would  otherwise  be  possible,  and,  as  will  be  seen  later, 
tubes  of  low  resistance  have  certain  advantages  over  those  with  a  high 
resistance.  (See  pages  46,  48.)  If  the  spark-gap  is  several  centimetres 
in  length,  the  light  may  not  be  quite  steady  and  there  is  noise. 


X-RAY    EOU I PM E N T 


17 


Adjustable  Multiple  Spark-gap.  —  To  permit  the  use  of  a  consider- 
able length  of  spark-gap  and  at  the  same  time  insure,  for  purposes 
of  examination  with  the  fluorescent  screen,  the  requisite  of  a  perfectly 
steady  light  I  some  years  since  devised  what  I  have  called  an  adjust- 
able multiple  spark-gap  (see  Fig.  8),  which  consists  of  a  series  of  small 
brass  balls  i^  centimetres  in  diameter,  fastened  about  3  millimetres 
apart  along  the  edge  of  a  strip  of  vulcanite  i  centimetre  wide.  This 
strip,  with  its  balls,  is  free  to  move  up  and  down  through  a  vertical 
brass  tube.  When  the  electricity  is  turned  on,  a  discharge  is  seen  to  go 
from  ball  to  ball,  and  a  larger  or  smaller  number  of  these  small  spark- 
gaps  can  be  brought  into  the  circuit,  according  to  the  amount  of  light 
desired.  In  1898  the  machine  was  provided  with  two  of  these  adjust- 
able multiple  spark-gaps,  one  at  each  terminal,  and  they  are  controlled 
by  the  cords  with  counter-weights  which  are  seen  hanging  at  the  left 
of  the  cut  (Fig.  59,  Chapter  III),  nearly  over  the  patient's  head. 
When  this  spark-gap  is  used  the  hght  is  steady  and  there  is  little 
noise ;  when  the  tube  does  not  require  a  spark-gap  the  heart  sounds 
can  be  heard  while  its  pulsations  are  watched  on  the  screen. 

Capacity  of  Machine.  —  The  capacity  of  this  machine  is  indicated  by 
the  larger  part  of  the  work  described  in  the  following  pages  ;  the  lesser 
portion  has  been  done  with  smaller  static  machines,  or  a  Ritchie  coil, 
or  an  A.  W.  L.  Universal  coil. 

Capacity  of  a  still  Larger  Machine.  —  Dr.  William  Rollins  and  I, 
while  using  his  static  machine,  so  far  as  I  am  aware  the  largest  ever 
made,  which  has  plates  of  the  same  size  as  mine,  but  double  the 
number,  could  plainly  see  the  heart  of  a  man  at  a  distance  of  about 
9  metres  (30  feet).  A  partition  prevented  us  from  observing  it  at  a 
further  distance.  Dr.  Rollins's  machine  and  mine  were  built  at  about 
the  same  time,  but  his  was  completed  earlier  and  I  profited  greatly  by 
his  experience. 

Small  Machines.  —  For  the  extremities  of  the  human  body  small  and 
inexpensive  static  machines  would  answer  in  dry  weather,  but  when  the 
practitioner  desires  to  make  examinations  of  the  trunk,  a  small  machine 
is  unsuitable.  A  machine  of  several  plates  of  about  90  centimetres  in 
diameter  is  necessary  for  medical  work,  but  larger  machines  are  more 
satisfactory. 

This  generator  (Fig.  9)  was  lent  me  by  Dr.  Rollins,  and  was  used 
for  some  time  in  my  work  at  the  Boston  City  Hospital  before  I  had 
a  larger  machine  made.     The  plates  are  one  metre  in  diameter.     In  dry 


1 8       THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

weather  this  generator  will  produce  sufficient  light  with  a  good  tube  for 
work  with  the  fluorescent  screen.  By  means  of  a  simple  reversing  switch, 
devised  by  Dr.  Rollins,  shown  on  the  top  of  the  case,  the  current  can 
be  sent  in  either  direction  through  the  tube.     As  it  is  impossible  to  tell 


Fig.  9.     Medium-sized  static  machine,  with  four  revolving  plates  one  metre  in  diameter.     (Rollins.) 


X-RAY    EQUIPMENT 


19 


•  which  terminal  of  a  static  machine  will  be  positive  before  the  machine 
lis  started,  this  is  a  convenient  arrangement. 

;  Thomson's  (Elihu)  Dynamo  Static  Machine.  —  This  machine  is  not 
ISO  much  influenced  by  moisture  as  the  Holtz  machine,  and  it  occupies 
;a  smaller  space. 

Induction  Coils 

^  The  usual  form  of  induction  coil  consists  of  a  primary  coil,  through 
j  which  the  exciting  current  of  electricity  is  passed,  and  a  secondary  coil, 
I — these  two  coils  being  separated  by  an  insulating  tube  of  hard  rubber ; 


Fig.  10.     Diagram  showing  the  construction  of  an  induction  coil.     (Roliins.j 


the  primary  coil  is  made  up  of  a  comparatively  few  turns  of  coarse  wire 
that  is  usually  wound  around  a  soft  iron  core  ;  the  secondary  of  many 
turns  of  fine  wire  that  is  generally  wound  over  the  tube  covering  the 
primary  coil,  but  is  sometimes  so  arranged  as  to  be  near  it,  not  over 
it.  Ritchie  invented  the  now  generally  adopted  method  of  winding  the 
secondary  in  sections.  In  the  circuit  of  the  primary  is  a  break  which 
interrupts  the  current ;  every  time  the  current  is  made  or  broken  in  the 
primary,  a  current  of  higher  voltage  is  induced  in  the  secondary.  It  is 
this  latter  current  which  is  sent  through  the  vacuum  tube. 

Condenser.  —  A  condenser,  that  is  made  up  of  many  sheets  of  tin 
foil  insulated  from  each  other  by  paper  coated  with  shellac,  is  placed  in 
the    primary   circuit   to   make    the    interruptions    of   the    current   more 


20     THE  roentg5:n  ravs  in  medicine  and  surgery 

sudden,  and  thereby  the  spark-length  of  the  coil  is  increased.     A  con-  1 
denser  is  not  required  when  an  electrolytic  interrupter  is  used. 

Size  of  Coil.  —  The  size  of  the  coil  is  estimated  by  its  maximum  spark-  j 
length.  A  coil  giving  a  spark-length  of  25  to  30  centimetres  is  usu-  1 
ally  considered  sufficient,  but  coils  with  a  higher  potential  are  better  ! 
because  tubes  with  much  lower  resistance  can  be  used  with  them  than  j 
with  those  of  lower  potential.  j 

Interrupter.  —  Many  devices  for  breaking  or  interrupting  the  current 
through  the  primary  have  been  employed.  Most  of  them  have  draw- 
backs which  in  practice  form  the  chief  obstacle  to  the  use  of  the  coil 
if  high  voltage  currents  are  used.  There  are  many  different  inter- 
rupters, and  the  kind  best  adapted  for  use  is  dependent  on  the 
voltage  ;  detailed  description  of  most  of  them  may  well  be  omitted. 
In  general  it  may  be  said  that  interrupters  that  make  and  break  the 
circuit  through  metallic  contact  wear  somewhat  rapidly,  especially  if 
the  voltage  is  as  high  as  no  volts.  This  wearing  is  often  the  cause  of 
troublesome  breakdowns. 

Mercury  Interrupter.  —  To  overcome    this  difficulty,  interrupters  in 
which  the  circuit  is  made  and  broken  by  means  of  a  jet  of  mercury,  and  ! 
which  are  known  as  mercury  interrupters,  have  been  devised. 

Electrolytic  Interrupters.  —  With  the  powerful  currents  which  can 
be  used  with  Rollins's  tubes  (see  pages  34  to  41),  the  hammer  and  rotary 
interrupters  in  their  various  forms  are  neither  steady  nor  durable.  The 
most  durable  mechanism  for  breaking  such  currents  is  some  form  of 
the  electrolytic  break  invented  by  Spottiswoode  and  described  in  Vol. 
XXV,  pp.  547-550  of  the  Proceedings  of  the  Royal  Society  for  1876-7. 
With  electrolytic  interrupters  the  usual  expensive  and  troublesome 
condenser  is  not  required,  and  two  small  Leyden  jars  suffice  for 
tuning. 

The  construction  of  the  electrolytic  interrupter  of  the  form  sug- 
gested by  Wehnelt  is  as  follows  :  Through  a  glass  tube  passes  a 
small  platinum  wire,  which  projects  from  the  sealed  end  of  the  tube 
only  enough  to  expose  i  or  2  square  millimetres  of  platinum  surface ; 
it  is  immersed  in  a  mixture  of  suljihuric  acid  and  water  having  a  specific 
gravity  of  1.2.  Into  this  liquid  there  also  dips  a  lead  plate.  The 
current  is  sent  through  the  solution  by  means  of  these  electrodes.  The 
platinum  terminal  should  be  connected  to  the  positive  wire  of  the  supply 
circuit,  and  the  lead  plate  to  the  negative  wire.  A  convenient  method 
of  ascertaining  which  is  the  positive  pole  is  to  place  a  strip  of  moistened 


X-RAY    EQUIPMENT 


21 


litmus  paper  upon  a  dry  board  or  other  insulating  material,  and  to  touch 
one  end  of  the  strip  with  a  wire  from  one  terminal  of  the  circuit,  and 
the  other  end  with  a  wire  from  the  other  terminal.  The  litmus  paper 
will  be  colored  red  about  the  positive  terminal.  Caution  is  necessary 
to  avoid  touching  the  two  sides  of  the  circuit  at  the  same  time  with  the 


11,0  VOLT* 


Fig.   II.     Heinze  interrupter.     O,  end  of  platinum  wire ;    F,  earthenware  jar ; 

6",  sulphuric  acid  solution.     (Rollins.) 

A  platinum  rod  is  moved  up  and  down  by  a  small  motor  through  the  opening  of  a  glass  tube 

immersed  in  dilute  sulphuric  acid,  the  rod  being  the  positive  terminal  through  which  the  current 

eniers.    The  negative  terminal  is  a  lead  plate.     This  is  the  steadiest  form  of  electrolytic  break  yet 

introduced. 

hands,  as  this  contact  might  result  in  disagreeable  shocks  or  burns  ; 
direct  connection,  technically  called  "  short-circuiting,"  between  the  two 
terminals  of  the  supply  should  also  be  avoided. 

This  interrupter  gives  a  very  rapid  make  and  break  of  the  circuit, 
produces  a  powerful  secondary  discharge,  and  may  be  placed  directly  in 


2  2        THE   ROENTGEN    RAYS   IN    MEDICINE    AND   SURGERY 

the  iio-volt  circuit,  but  cannot  be  used  with  a  current  of  much  below 
50  volts.  Its  disadvantage  is  that  it  is  liable  to  stop  altogether  after 
a  short  time.  This  serious  difficulty  I  have  overcome  by  putting  a 
commutator  in  the  circuit  with  the  interrupter.  By  this  means  the 
severe  strain  on  the  coil  and  the  tube,  the  production  of  which  is  the 
disadvantage  of  all  electrolytic  interrupters,  is  lessened.  To  this  combi- 
nation I  have  given  the  name  of  Interrupted  Electrolytic  Interrupter.i 

By  the  use  of  the  principle  of  interrupting  the  electrolytic  inter- 
rupter, Heinze  has  constructed  an  electrolytic  interrupter  (see  Fig.  11), 
a  cut  of  which  is  here  given ;    recently  he  has  devised  a  better  form. 

Source  of  Current.  —  A  supply  from  the  street  mains,  when  avail- 
able, forms  the  most  convenient  source  for  obtaining  the  primary  cur- 
rent. The  house  wires  from  the  street  may  be  connected  through  the 
interrupter  to  the  primary  terminals. 

Apparatus  for  reducing  Voltage.  —  The  street  supply  is  usually  1 10 
volts.  This  high  voltage  rapidly  destroys  some  forms  of  interrupter, 
and  therefore  when  such  forms  must  be  used  it  is  advantageous  to 
reduce  the  voltage  either  by  means  of  a  motor  genefator  (which  is  an 
electric  motor  and  dynamo  combined),  or  a  small  storage  battery.  The 
former  is  preferable,  but  by  either  means  the  voltage  can  be  reduced 
as  low  as  is  desired. 

Rheostat.  — ■  This  instrument  is  used,  when  necessary,  to  reduce  the 
amperage  when  employing  a  street  current.  There  are  three  usual 
forms :  the  water,  the  carbon,  and   the  wire  rheostat. 

Adjustment  for  varying  the  Light.  —  When  the  fluorescent  screen  is 
used  it  is  essential  to  be  able  to  vary  the  amount  of  light  while  the 
examination  is  being  made,  and  this  end  may  be  accomplished  by 
adjustments  which  enable  the  operator  to  vary  the  speed  of  the  inter- 
rupter, the  amperage,  the  amount  of  the  condenser,  and  the  length  of  j 
the  spark-gap.  All  coils  for  use  with  the  fluorescent  screen  should  there- 
fore have  some  or  all  of  these  adjustments. 

A.    Page  or  RuJtnikoTff  Type  of  Coil 

The  following  cuts  will  serve  to  illustrate  Avays  in  which  a  coil  of 
this  type  may  be  excited.  The  coil  shown  in  the  figures  is  a  Ritchie 
coil,  and  with  a  current  of  low  voltage  (8-1 0  volts)  the  usual  hammer 

^  Electrical  Review,  July  26,  1899. 


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23 


break  or  vibrator  is  used;  with  a  current  of  high  voltage  (i  10-220 
volts),  sonie  more  durable  form  of  interrupter  than  a  vibrator  should 
be  employed,  —  such  an  one,  for  instance,  as  the  electrolytic  interrupter 
shown  on  page  21. 


Fig.  12.     Shows  primary  battery,  Ritchie  coil  with  hammer  interrupter,  and  tube. 

The  place  for  one  of  the  two  multiple  spark-gaps  is  indicated  in  this  and  the  following  cuts  by  a  card 

on  which  are  the  letters  SG. 


Fig.  13.     Shows  storage  battery.  Ritchie  coil  with  hammer  interrupter,  and  tube. 


24 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


Fig.  14.      Shows   motor-generator,    Ritchie  coil  with  hammer  interrupter,   and  tube. 

A  motor-generator  is  a  small  dynamo  combined  with  an  electric  motor.    Instead  of  a  motor-generator 

a  small  dynamo  may  be  used  that  can  be  run  by  a  water  motor  or  a  gasoline  engine. 


Fig.  15.     Shows  Ritchie  coil  charged  from  street  main,  Wehnelt  electrolytic  interrupter, 

and  tube. 


X-RAY    EQUIPMENT 


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Fig.  16.     Heinze  electrolytic  interrupter,  Ritchie  coil,  and  tube. 


Fig.  17.  Adjustable  multiple  spark-gap  on  Ritchie  coil,  as  arranged  by  Rollins.  .Sand  7",  terminals 
of  coil;  U,  ball  on  end  of  spark-gap  rod  C;  R,  row  of  brass  balls  on  strip  of  mica;  J,  wire  to 
vacuum  tube.     (Rollins.) 


26       THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


Fig.  i8.  Adjustable  multiple  spark-gap  for  coil. 
This  cut  shows  an  end  view  of  the  coil,  with  a  simple  form  of  adjustable  multiple  spark-gap, 
in  which  the  brass  balls  are  held  on  the  side  or  edge  of  a  strip  of  insulating  material.  There  are  two 
of  these  on  the  coil,  one  at  each  end  of  the  secondary.  The  letters  SG  in  the  preceding  cuts  indicate 
the  position  of  one  of  the  spark-gaps.  Dr.  Rollins  has  previously  used  another  form  of  adjustable 
multiple  spark-gap  with  brass  balls  supported  on  mica  on  his  coil  (see  Figs.  21  and  22)  ;  later  he  used 
it  on  a  Ritchie  coil. 

Norton  and  Lawrence  Apparatus. ^  —  This  apparatus  was  devised  by 
Messrs.  Norton  and  Lawrence  of  the  Massachusetts  Institute  of  Tech- 
nology ;  it  has  a  short  primary  of  thick  wire,  and  was  designed  to  be 
supplied  directly  from  the  street  main.  The  condenser  consists  of 
sheets  of  tinfoil  placed  between  larger  sheets  of  insulating  material, 
such  as  mica  or  prepared  paper,  and  is  charged  from  the  interrupter 
and  discharged  through  the  primary  (method  devised  by  Mr.  Lawrence), 
the  amount  or  quantity  of  the  discharge  being  increased  by  increasing 
the  surface  or  number  of  plates  of  the  condenser.  The  amount  of  the 
condenser  may  be  varied  from  lo  to  200  microfarads  by  means  of 
switches,  and  these  switches  are  so  placed  that  the  physician  can  reach 
them  while  continuing  his  examination,  and  throw  in  more  or  less  of 
the  condenser,  as  the  needs  of  the  moment  may  require. 

In  order  to  adapt  to  medical  practice  the  above-mentioned  apparatus, 

'  A  description  of  this  apparatus  may  be  found  in  the  following  journals :  Science,  Febru- 
ary 26  and  March  26,  1897;   ^^atwe,  March  18,  1897;    Electrical  Engineer,  March  24,  1897. 


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27 


Messrs.  Norton  and  Lawrence,  at  my  suggestion,  subdivided  the  con- 
denser, made  the  speed  of  the  interrupter  variable,  and  put  in  an 
adjustable  spark-gap  (see  page  26).  Without  these  adjustments  the 
apparatus  would  not  be  suitable  for  examinations  of  the  chest.  I  also 
found  it  desirable  to  use  a  slate  wheel,  and  to  employ  Van  Depoele's 
principle  of  carbon  brushes  instead  of  metallic  contacts  on  the  inter- 
rupter, and  experiment  showed  me  that  two  or  more  brushes  were  better 
than  a  single  one.       I   have  run  this  commutator   on  a  220-volt  circuit 


Fig.  19.  Cut  of  portable  apparatus  for  use  on  iio-volt  circuit.  The  smaller  box  contains  the  coil; 
the  larger,  the  interrupted  electrolytic  interrupter,  two  vacuum  tubes,  and  the  tube-holder.  The 
tube-holder  is  shown  fastened  to  the  smaller  box. 

continuously  for  four  hours  ;  at  least  half  of  this  time  with  a  flow  of 
2I  to  3  amperes.  The  tube  used  was  a  self-regulating  one  devised  by 
Dr.  Rollins,  and  it  gave  a  steady  light  during  the  whole  of  this  time. 

Portable  Apparatus. — This  whole  apparatus  (Fig.  19)  weighs  40 
pounds  and  can  be  easily  carried  by  a  man,  one  box  in  each  hand.  In 
places  where  no  i  lO-volt  circuit  is  available,  I  have  used  an  electric  cab 
or  carriage  bv  running  insulated  wires  from  the  storage  battery  in  the 
cab  to  the  patient's  room,  and  connecting  them  with  an  X-ray  apparatus. 


28       THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

B.    HigJi  Frequency  Coils 

In  the  high  frequency  coil  the  potential  is  increased  by  sending  through 
its  primary  the  current  from  the  secondary  of  an  ordinary  induction  coil. 
The  diagram,  Fig.  20,  illustrates  the  construction  of  a  high  frequency 
coil.  It  has  a  primary  of  coarse  wire,  through  which  is  passed  the 
current  from  the  secondary  of  the  first  coil,  a  spark-gap  and  condenser 


Diagram  of  high  frequency  coil.     (Rolhns.) 


being  inserted  ;  and  a  secondary  that  has  but  a  few  turns  of  fine  wire. 
Instead  of  the  construction  shown  in  the  figure,  the  primary  and  second- 
ary may  be  wound  flat  and  made  to  face  each  other.  In  most  high  fre- 
quency coils  the  insulation  is  so  difficult  that  all  the  parts  are  immersed 
in  oil. 

A.   IV.  L.  Universal  Coil 

This  is  a  form  of  coil  for  X-ray  and  electrotherapeutic  work  that 
was  designed  by  Dr.  Rollins  and  named  the  A.  W.  L.  Universal  Coil, 
and  was  first  used  in  December,  1900.  Through  Dr.  Rollins'  kindness 
I  had  the  use  of  the  first  one  at  the  Boston  City  Hospital.  It  is  run  on 
a  1 10- volt  circuit,  and  when  an  electric  main  is  not  available,  as  in  the 
country,  the  current  may  be  obtained  from  a  small  dynamo  run  by  a 
small  gasolene  engine.     This  coil  differs  from  others  in  several  ways. 


X-RAY   EQUIPMENT 


29 


First :  The  thick,  hard  rubber  tube  used  in  all  coils  to  insulate  the 
primary  from  the  secondary  is  not  employed  in  this  one,  for  Rollins 
found  by  experiment  that  mica  was  the  best  material,  and  that  mica 
tubes,  two  centimetres  thick,  made  by  the  Micanite  Company,  of  Sche- 
nectady, New  York,  will  allow  a  strong  current  to  be  used  to  excite  a 
tube,  without  risk  of  injury  to  the  coil. 


Fig.  21.    A.  W.  L.  universal  coil.    43  centimetres.     (Rollins.) 
In  this  coil  the  amperage  and  potential  of  the  currents  are  under  perfect  control.     With  a  43- 
centimetre  coil,  the  current  can  be  varied  from  a  discharge  of  great  power  to  one  so  light  as  to  be  but 
slightly  felt  when  it  passes  through  the  body.      All  forms  of  currents  used  in  electrotherapeutics  can 
be  obtained  with  it. 

Second:  The  universal  methods  of  insulating  the  coils  of  the  sec- 
ondary with  wax  or  oil  are  not  used  ;  air  takes  their  place.  The  secondary 
is  entirely  free  from  the  tube  surrounding  the  primary.  Each  sub-coil  of 
the  secondary  is  permanently  attached  to  a  sheet  of  glass  two  milli- 
metres thick  which  serves  to  separate  it  from  the  next  sub-coil.     Two  of 


30        THE    ROENTGEN    ILWS   IN    MEDICINE   AND   SURGERY 

these  form  a  section  ;  and  these  sections,  varying  in  number  from  56 
upward,  according  to  the  size  of  the  coil,  are  strung  loosely,  like  beads 
on  a  string,  on  a  micanite  tube  which  separates  the  secondary  from  the 
primary  coil. 

With  the  previous  types  of  coil  it  was  difficult  to  make  repairs, 
because  it  was  necessary  to  draw  off  the  oil  or  to  melt  out  the  wax 
before  the  secondary  could  be  reached.  Even  when  this  had  been  done 
the  defect  was  hard  to  find.  With  this  new  type  of  coil  the  short 
circuit  can  easily  be  located,  as  the  wires  from  each  section  can  be 
tested  without  disturbing  the  secondary ;  when  the  defective  section 
has  been  found,  the  micanite  tube  is  simply  withdrawn  far  enough  to 
permit  the  removal  of  this  section.  A  new  section,  always  kept  in 
reserve,  can  then  be  put  in. 

Third :  The  potential  and  amperage  of  the  coil  can  be  regulated 
without  changing  the  current  flowing  in  the  primary. 

The  potential  can  be  varied  by  means  of  wires  brought  up  from 
every  seventh  section  to  a  row  of  brass  balls  in  a  glass  plate  abo^■e  the 
coil.  The  number  of  sections  used,  and  thus  the  potential,  can  be 
changed  as  desired  from  one  centimetre  to  the  full  length  of  the  coil. 

The  amperage  is  changed  by  an  arrangement  which  allows  the  pri- 
mary to  slide  in  or  out,  and  thus  the  amount  of  current  induced  in  the 
secondary  is  varied.  This  method  of  regulating  the  amperage  has 
been  employed  in  very  small  coils,  but  not  on  coils  suitable  for  exciting 
X-ray  tubes. 

The  power  to  control  the  potential  and  amperage,  and  the  other 
means  to  be  mentioned  later  for  varying  the  discharges,  enables  the 
physician  not  only  to  excite  X-ray  tubes  with  this  coil,  but  also  to  use 
it  for  electrotherapeutic  work,  and  therefore  a  static  machine  and  a 
high  frequency  coil  in  addition  become  unnecessary.  Dr.  Rollins, 
therefore,  believes  that  the  static  machine  will  gradually  retire  to  the 
seclusion  of  the  physical  laboratories  from  which  it  emerged  when  the 
X-rays  were  discovered. 

Fourth :  A  multiple  spark-gap  is  provided  for  controlling  the  cur- 
rent so  that  it  may  be  sent  in  discharges  suitable  to  the  condition  of  the 
tube.  The  importance  of  employing  this  appliance  or  some  other  form 
of  resistance  on  a  coil  as  well  as  on  a  static  machine  (see  page  17  and 
page  48)  is  easily  shown  by  using  a  tube  of  low  resistance.  Without 
this  multiple  spark-gap  or  some  other  form  of  resistance  no  light  is  seen, 
but  with  it  bright  light  is  produced. 


X-RAY    EQUIPMENT 


31 


Fifth:  Methods  are  provided  for  varying  the  kinds  of  current  used. 
The  coil  gives  the  so-called  unidirectional  current  when  the  connection 
is  made  with  the  principal  terminals.  If  an  alternating  current  is 
desired,  connection  is  made  with  the  terminals  of  the  interior  coatings 
of  the  Leyden  jars.  If  a  current  of  still  higher  frequency  is  wanted,  a 
small  Tesla  coil  is  inserted  in  the  Leyden  jar  circuit.  If  a  current  for 
cautery  is  required  (one  of  low  voltage  and  large  amperage),  a  step- 
down  transformer  of  a  few  turns  of  coarse  wire  is  slipped  over  the 
primary,  which  is  partly  withdrawn  so  that  the  wire  may  be  put  on. 


Fig.  22.     Diagram  of  A.  W.  L.  universal  coil.     (Rollins.) 

Sixth  :  The  spark-gaps  are  enclosed  in  tight  tubes  of  glass  to  pre- 
vent the  escape  of  gases  that  irritate  the  respiratory  mucous  membrane  ; 
these  gases  may  be  removed  by  means  of  an  aspirator  connected  by  a 
rubber  tube  with  the  spark-gaps.  This  aspirator  can  be  attached  to  the 
nearest  basin  faucet  when  desired,  and  the  gases  be  discharged  into  the 
water  pipe.  The  metal  balls  of  the  spark-gap,  and  the  interior  of 
the  glass  tubes,  will  become  coated  with  substances  having  an  acid 
reaction,  as  the  coil  is  used  ;  and  as  in  this  case  they  become  conductors, 
they  must  be  cleansed  with  ammonia  water  and  then  dried. 

Apparatus  for  Physicians  in  the  Country,  where  an  Electric  Main  is 
not  Available.  —  K.  A  Static  Machine  which  may  be  run  by  a  gasolene 
eno-ine. 


32        THH    ROEiNTGEN    RAVS    IN    MEDICINE    AND    SURGERY 

B.  I.  A  Coi7  which  is  run  by  a  combination  of  storage  battery  and 
gravity  cells.  The  apparatus  shown  (see  Fig.  23)  consists  of  a  30 
centimetre  Ritchie  coil  which  is  placed  on  the  top  of  a  case  containing 
24  gravity  cells  that  are  permanently  attached  to  four  Willard  storage 
batteries  of  50  ampere  hours.  As  the  gravity  cells  are  constantly  send- 
ing electricity  into  the  reservoir  there  should  always  be  enough  energy 
stored  to  enable  the  operator  to  use  40  watts,  which,  with  the  aid  of 
Ritchie's  remarkably  economical  induction  coil.  Dr.  Rollins  has  found  to 
give  ample  light  for  one  hour  a  day,  if  suitable  tubes  are  used,  for  work 
with  the  fluorescent  screen  or  for  taking  X-ray  photographs. 

2.  A  Coil  which  is  run  by  means  of  storage  cells  that  are  charged 
by  a  small  dynamo  that  is  driven  by  a  gasolene  engine.  These  storage 
cells  are  used  in  one  of  two  ways.  First,  four  storage  cells  of  large 
capacity  are  employed,  if  the  coil  is  wound  to  use  a  low  voltage  (about 
8  volts)  like  a  Ritchie  coil.  Second,  fifty  smaller  storage  cells  are  used 
for  an  A.  W.  L.  universal  coil  which  is  run  on  an  i  lo-volt  circuit. 

Trowbridge's  directly  Connected  System. — The  vacuum  tube  may 
also  be  excited  by  a  storage  battery  that  is  charged  from  the  street  main. 
Jhis  apparatus  gives  a  unidirectional,  steady  current,  and  with  a  suit- 
able tube  the  amount  of  X-light  is  very  great.  The  tube  is  directly 
connected  with  10,000  to  20,000  storage  cells  in  series  through  a  water 
rheostat.     This  method  is  not  as  yet  used  in  practice. 


Vacuum  Tubes  for  Producing  X-Rays 

Whether  one  uses  a  static  machine  or  an  induction  coil  as  an  exciter, 
the  vacuum  tube  still  remains  the  most  important  portion  of  the  appa- 
ratus and  the  most  difficult  to  keep  in  proper  condition.  It  consists 
mainly  of  a  glass  bulb  about  10  centimetres  in  diameter,  in  the  interior 
of  which  are  supported  on  metal  stems  two  or  three  metallic  objects, 
according  to  the  kind  of  tube  employed. 

A.  Double  Focus  Tubes.  —  These  tubes  are  used  on  an  alternat- 
ing current  and  contain  three  pieces  of  metal  —  the  two  terminals, 
called  respectively  the  cathode  and  the  anode,  and  the  third  the  anti- 
cathode,  or  target.     See  Figs.  32-35. 

B.  Single  Focus  Tubes.  —  These  tubes  are  used  on  a  direct  current 
and  contain  the  two  terminals  called  respectively  the  cathode  and  the 
anode  ;  this  latter  terminal  acting  as  a  target  also.    See  Figs.  24-28,  30-3 1 . 


X-RAY  EQUIPMENT 


33 


Fig.  23.    Combination  of  storage  battery  and  gravity  cells.    The  tube  holder  is  seen  in  position 
with  one  side  removed  so  that  the  tube  is  visible.     In  front  of  tube  is  a  circular  diaphragm  with 
an  aluminum  wire  screen  in  its  centre.     The  case  is  filled  with  storage  batteries  and  gravity  cells, 
some  of  which  are  seen  on  the  left.     (Rollins.) 
D 


34 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


Cathode.  —  The  cathode  is  made  of  aluminum,  and  is  usually  a  con- 
cave disk,  which  has  a  radius  of  curvature  of  about  3.5  centimetres,  and 
should  be  placed  at  twice  this  distance  from  the  target.  The  diameter 
of  the  cathode  should  vary  with  the  size  of  the  discharges  used  to  excite 
the  tube  ;  if  these  are  large,  the  cathode  should  be  large. 

Anode.  —  The  anode,  in  the  double  focus  tube,  that  is,  when  a 
terminal  only,  is  made  of  aluminum  (see  Figs.  32-35). 

Target.  —  The  target  receives  the  impact  of  the  cathode  stream  (see 
Fig.  31).       It  should  be  made  of  platinum   alloyed  with  iridium,   and 


Fir..  24.     A.  W.  L.  rotary  target  tube  with  movable  target.     (Rollins.) 

This  cut  shows  a  curved  target  supported  by  a  strong  stem  which  can  be  slid  in  or  out  by  the 
action  of  a  sliding  weight  attached  to  it  (the  dark  mass  on  the  stem  represents  the  weight),  and  thus 
the  distance  between  the  target  and  cathode  can  be  changed  until  the  best  distance  has  been 
determined. 


Fig.  25.    A.  W.  L.  rotary  target  tube  with  movable  target  and  internal  diaphragm.     (Rollins.) 
This  cut  shows  a  similar  adjustable   target  with  a   diaphragm,  supported  on   the  same  stem, 
above  it.    The  cone  of  rays,  and  the  widening  of  this  cone  as  its  distance  from  the  target  increases,  is 
represented  by  the  two  lines  running  at  an  angle  to  the  diaphragm. 

should  be  placed  at  an  angle  of  fifty-six  degrees  with  the  cathode  stem 
in  the  real  focus,  but  not  in  the  centre  of  curvature,  of  the  cathode. 

Crookes,  Roentgen,  and  others  placed  the  target  in  the  centre  of 
curvature  of  the  cathode  ;  Frei,  whose  tubes  were  superior,  soon  departed 
from  this  type,  and  placed  the  target  from  three  to  four  times  this  dis- 
tance. Rollins  has  found  by  experiments  with  his  movable  terminals 
(see  Fig.  24  and  Fig.  25)  that  when  the  tube  was  exhausted  to  the 
degree  of  resistance  required  for  the  most  economical  production  of 
X-rays,  the  real  focus  of  the  cathode  stream  was  between  these  two 


X-RAY   EQUIPMENT  35. 

extremes.  In  his  Notes,  published  in  the  Electrical  Review,  he  has 
suggested  as  an  explanation  of  this  phenomenon  that  the  particles  of  the 
cathode  stream  are  charged  with  the  same  kind  of  electricity,  and 
therefore  would  repel  each  other,  with  the  result  that  they  would  come 
to  a  focus  beyond  the  theoretical  point. 

The  two  preceding  figures  represent  two  of  the  early  forms  of  experi- 
mental single  focus  tubes  devised  by  Dr.  Rollins  for  the  purpose  of 
ascertaining  the  best  distance  of  the  target  from  the  cathode. 

Good  tubes  now  have  the  target  placed  in  the  position  recommended 
by  him  ;  that  is  to  say,  about  twice  the  theoretical  distance.  The  mat- 
ter is  of  practical  importance,  as  the  ability  to  obtain  sharp  definition  is 
partially  dependent  upon  the  position  of  the  target. 

Anode  and  Target  United.  —  The  anode  and  target  are  combined  in 
the  single  focus  tube  (see  Figs.  24-31 ),  and  under  these  circumstances  this 
object  should  be  made  of  the  alloy  above  described,  and  placed  at  the 
same  angle  with  the  cathode,  as  is  the  target  when  it  is  an  independent 
object.  Lodge  and  Rowland  have  observed  that  when  the  target  was 
united  with  the  anode,  the  tube  was  more  efficient  than  when  separated 
from  it.  Rollins  states  that  this  increased  efficiency  is  due  to  the  fact 
that  the  particles  in  the  cathode  stream,  being  negatively  charged,  are 
attracted  as  they  approach  the  target  when  it  is  combined  with  the  an- 
ode, for  the  latter  is  always  positively  charged,  and  consequently  strike 
it  at  a  higher  velocity. 

The  target,  whether  independent  or  combined  with  the  anode, 
should  be  0.43  of  a  millimetre  or  more  in  thickness  in  order  to  with- 
stand so  far  as  is  practicable,  by  means  of  size,  a  strong  electric  current ; 
for  if  the  exciter  has  much  energy  and  the  metal  is  thin,  it  becomes  hot 
sooner  and  is  more  easily  melted.  To  further  resist  the  effect  of  a 
strong  current.  Dr.  Rollins  de\ased  for  me,  in  1896  and  1897,  two  very 
ingenious  forms  of  target,  the  target  being  placed  at  twice  the  theoretical 
distance  from  the  cathode,  as  described  above.  The  first  is  hollow  (see 
Figs.  26,  27)  and  is  closed  at  one  end  but  open  at  the  other,  so  that  a 
stream  of  water  may  be  kept  running  through  it,  or  a  current  of  air  may 
be  driven  through  it,  and  thus  the  target  is  prevented  from  becoming 
hot  and  being  destroyed.  So  far  as  I  am  aware,  this  is  the  only  form  of 
target  that  will  withstand  extreme  amounts  of  electric  energy.  The 
second  is  a  rotary  target  (see  Figs.  28,  29),  and  is  supported  on  a  pivot  in 
its  centre,  so  that  if  one  part  of  the  target  is  destroyed  by  having  a  small 
hole  melted  in  it,  a  slight  shaking  of  the  tube  will  bring  another  portion 


36       THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

of  the  target  into  the  focus  of  the  discharge  from  the  cathode.  In  a 
third  form,  Fig.  24,  the  target  was  made  concave  in  the  hope  that 
this  form  would  collect  the  X-rays  that  would  otherwise  be  lost.  In 
these  tubes  the  supports  of  the  terminals  are  strong  stems  of  metal, 
and  the  glass  wrappings  (see  Fig.  30)  are  dispensed  with. 
Single  Focus  Tubes  for  Use  with  the  Direct  Current. 


A-W-L     X-LIGHT    TUBE. 


Fig.  26.     Cooled  target  tube.     The  tube  is  43  centimetres  long.     (Rollins.) 


A-W-L  X-LIGHT    TUBE. 


OUTLET  TUBE 


UNLET  TUBE 
FOR  COOLING 
AIR    OR  WATER 

HOLLOWJ-LATINUM  TARGET 


Fig.  27.     Section  of  cooled  target  tube.     (Rollins.) 


The  A.  W.  L.  tube  for  direct  currents.  Rotary  target  type.  (Rollins.) 
This  illustrates  a  form  of  tube  which  I  have  used  in  some  of  my  work.  It  was  designed  for  me 
by  Dr.  Rollins.  The  target  may  be  rotated  by  jarring  the  tube.  If  a  hole  should  be  melted  in  the 
target  by  the  heat  produced  by  the  impact  of  the  cathode  stream,  a  fresh  surface  can  be  brought  into 
position,  thus  making  the  tube  as  useful  as  a  new  one.  If,  however,  the  target  is  sufficiently  thick,  it 
is  rarely  melted.  It  must  be  remembered  that  when  this  fresh  surface  is  first  used  the  resistance 
of  the  tube  may  be  temporarily  lowered,  as  gas  is  liberated. 

The  curved  disk  on  the  right  of  the  glass  bulb  is  the  cathode,  and  is  made  of  aluminum.     The 
metal  disk  in  the  middle  of  the  bulb  is  the  anode,  upon  which  the  rays  from  the  cathode  are  focussed. 


i 


X-RAY    EQUIPMENT 


2>7 


FOCUS  OF  CATHODE  STREAM. 


Fig.  29.  Details  of  rotary  target.  Full  size.  (Rollins.) 
The  rotary  target  is  liable  to  be  turned  somewhat  on  its  pivot  if  the  tube  is  transported  some  dis- 
tance, and  as  the  effect  of  exposing  a  new  surface  to  the  impact  of  the  cathode  stream  may  be  to  lower  the 
resistance  of  the  tube  (see  page  45),  a  tube  of  this  type  should  be  examined  by  the  practitioner  before 
it  is  used,  in  order  that  he  may  learn  whether  or  not  the  target  has  been  so  shaken  that  it  has  turned 
on  its  pivot.  This  point  can  be  determined  by  observing  whether  or  not  the  spot  that  has  been 
roughened  by  the  impact  of  the  cathode  stream  is  in  line  with  the  centre  of  the  cathode ;  if  not,  it 
must  be  shaken  into  line. 

The  following  figure  illustrates  a  not  uncommon  form  of  construction, 
which  is  faulty,  in  that  the  target  is  in  the  centre  of  curvature  of  the 
cathode  disk,  and  that  the  wrappings  of  the  stem  are  of  glass,  which  are 
liable  to  break  both  in  use  and  in  transportation,  with  the  result  that  the 
terminals  get  out  of  line. 


Fig.  30.     Tube  of  a  faulty  type  of  construction.     Target  in  centre  of  curvature  of  cathode;  wrap- 
pings of  stem  are  of  glass. 


Double  Focus  Tubes  for  Use  with  an  Alternating  Current.  —  With  the 
powerful  currents  that  may  be  used  with  high  frequency  coils,  holes  are 
liable  to  be  melted  in  the  target  by  the  heat  produced  by  the  impact  of 
the  cathode  stream,  and  the  tubes  be  rendered  useless.  To  overcome 
this  defect.  Dr.  RolUns  has  designed  double  focus  tubes  containing 
either  his  cooled  or  rotary  target.  A  second  objection  to  the  double 
focus  tubes  is  that  they  have  two  sources  from  which  the  X-rays  origi- 
nate (see  Fig.  32);  the  definition,  therefore,  is  not  so  good  as  it  may  be 
with  a  single  focus  tube.  To  obviate  this  objection  to  the  use  of  alternat- 
ing currents.  Dr.  Rollins  has  designed  the  tubes  shown  in  Figs.  33-35  — 
one  the  cooled  target  type,  and  the  other  of  the  rotary  target  type.  When 
these  tubes  are  used  as  double  focus  tubes  with  high  frequency  currents, 
one  radiant  area  is  formed  on  the  back  of  the  target,  or  that  side  facing 


-8       THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

away  from  the  patient.  The  X-rays  from  this  radiant  area  are  sent  out 
of  the  field,  exerting  no  injurious  action  on  the  definition,  if  the  tube  is 
in  a  suitable  opaque  box,  as  shown  in  Fig.  33.  Dr.  Rollins  prefers  to 
use  these  tubes  in  another  way,  however,  the  central  piece  of  metal 
being  always  one  terminal  through  which  the  current  passes,  instead  of 
simply  a  target,  having  no  connection  with  the  generator.     There  is  in 


LL 


-^^^ 

1 

T'  ;■  -  1 

0 

Fig.  31.     Illustrates  the  formation  of  the  cathode  stream  and  X-rays.     (Rollins.) 

The  cathode  stream  is  represented  by  dotted  lines,  the  X-rays  by  unbroken  lines.  When  the 
cathode  stream  strikes  the  target,  X-rays  are  given  off  in  all  directions  from  the  point  of  contact,  but 
only  one-half  of  the  sphere  is  seen,  as  the  other  half  is  obstructed  by  the  platinum  of  the  target.  In 
the  figure  these  rays  are  represented  as  passing  through  the  aluminum  of  the  cathode  and  the  glass 
walls  of  the  tube  until  stopped  by  the  white  lead  lining  of  the  box.  A  cone  of  X-rays,  large  enough 
to  cover  the  part  of  the  patient  to  be  examined,  is  allowed  to  escape  through  the  hole  in  the  revolving 
diaphragm  plate.  LL,  lead  lining  composed  of  white  lead  and  japan ;  J^P,  rubber  plugs  through 
which  pass  the  wires  .-/  and  Cfrom  the  electric  generator.  HD,  revolving  diaphragm  plate,  lined  like 
the  box,  with  lead ;  SL/,  screen  holder,  carrying  the  opaque  iron  screen  TD,  which  is  provided  with 
an  aluminum  gauze  window,  AS.     The  screen  is  grounded. 


consequence  but  one  radiant  area  on  the  target  from  which  the  rays 
can  arise,  for  the  target  is  struck  by  but  one  cathode  stream.  During 
the  periods  when  the  central  piece  of  metal  acts  as  a  cathode,  it  sends  a 
diffused  cathode  stream  toward  one  end  of  the  tube,  but  as  the  X-rays 
formed  by  the  impact  of  this  stream  arise  from  whatever  area  it  strikes, 
they  are  not  intense  enough  when  they  escape  through  the  opening  in 


X-RAY    EQUIPMENT 


39 


the  diaphragm  to  seriously  injure  the  definition.  The  second  cathode 
is  never  connected  with  the  generator  until  the  first  used  cathode  is  so 
exhausted  of  gas  that  the  resistance  of  the  tube  is  too  high,  then  it  may 
take  the  place  of  the  exhausted  cathode,  thus  delaying  for  a  longer  time 
the  necessity  of  using  the  regulator  for  introducing  fresh  gas  (see 
page  45).     The  single  focus  or  vacuum  tube  may  be  used  with  high 


US 

o   1 

LL 


Fig.  32.     Double  focus  tube  for  high  frequency  coils.     (Rollins.) 

The  cathode  streams  are  represented  by  dotted  lines,  the  X-rays  by  full  lines.  There  are  two 
cathode  streams,  and  consequently  two  sources  from  which  X-rays  arise.  This  double  source  of  light 
is  a  defect  of  the  type.  The  cooled  target  designed  by  Rollins  has  been  added  to  this  tube  :  for  further 
description,  see  page  35,  Figs.  26  and  27, 


frequency  currents  on  the  same  principle  ;  the  diffused  X-light  arising 
from  the  spreading  cathode  stream  given  off  by  the  target,  when  acting 
as  a  cathode,  cannot  injure  the  definition  seriously,  if  the  tube  is  always 
used,  as  it  should  be,  in  an  opaque  box  as  shown  in  Fig.  31. 

Tube  with  Continuous  Metallic  Conductor.  —  Professor   Trowbridge 
has  produced,  with  a  high  potential,  brilliant  X-rays  in  a  vacuum  tube 


40       THE  ROENTGEN   RAYS  IN   MEDICINE  AND   SURGERY 


Fig.  33.     A.  W.  L.  X-light  tube  for  high  frequency  coils  (cooled  target  type).      (Rollins.) 

A  form  of  tube  for  use  with  high  frequency  coils.  Two  cathode  streams,  represented  by  dotted 
lines,  strike  the  target,  producing  two  sources  from  which  X-rays  arise;  the  rays  from  one  source, 
which  are  represented  by  full  lines,  are  those  used.  The  rays  represented  by  broken  lines  are  dis- 
carded, being  thrown  away  from  the  patient  and  absorbed  by  the  opaque  lining  of  the  box,  and  thus 
they  do  not  injure  the  definition.  This  figure  should  be  compared  with  Figs.  31  and  32,  which  show 
the  origin  and  disposition  of  the  rays  in  two  other  types  of  tubes. 

with   a  continuous   metallic   conductor,   which   shows   that   to   produce 
X-rays  separate  terminals  are  not  necessary.     (Fig.  ^i^.) 

Effect  of  the  Glass  on  the  Passage  of  the  Rays.  —  How  little  obstacle 
the  thin  portion  of  the  glass  bulb  offers  to  the  passage  of  the  rays  may 


Fig.  34.    A.  W.  L.  tube  with  cooled  target  (for  alternating  currents).     (Rollins.) 


X-RAY   EQUIPMENT 


41 


be  determined  by  interposing  a  tube  of  good  construction  between  the 
excited  tube  and  the  fluorescent  screen,  and  observing  how  slight  is  the 
shadow  cast  upon  the  latter. 


Fig.  35.    A.  W.  L.  tube  with  rotary  target  (for  alternating  currents).     (Rollins.) 

In  these  tubes,  one  cathode  stream  striking  the  back  of  the  target  is  sent  out  of  the  field.  As  only 
one  radiant  area  on  the  target  sends  light  to  the  patient,  the  image  on  the  plate  or  screen  is  as  sharp 
as  when  a  single  focus  tube  is  used  with  a  direct  current.  The  tubes  may  be  used  as  single  focus 
tubes  with  a  direct  current  by  making  the  target  act  as  an  anode  also.  This  tube  is  the  same  type  as 
that  seen  in  Fig.  33,  which  shows  the  origin  and  distribution  of  the  X-rays. 


Exhaustion  of  Tube.  —  The  vacuum  tube  should  be  exhausted  to  a 
suitable  degree,  and  this  exhaustion  may  be  accomplished  by  a  mercury 
or  mechanical  pump,  the  tube  being  kept  during  the  earlier  part  of  the 
process  at  about  350°  F.  When  the  proper  point  of  exhaustion  has 
been  reached  the  tube  is  "  sealed  off."  There  are  various  precautions 
that  must  be  taken  against  moisture,  and  in  the  adjustment  of  the  tube 
to  the  proper  vacuum,  but  they  are  chiefly  of  interest  to  the  manufacturer 
and  need  not  concern  us  here. 


Fig.  36.     Tube  with  continuous  metallic  conductor.     '^Rollins.) 

Arrangement  for  connecting  Tube  with  Generator.  —  Metal  stems  run 
from  the  terminals  to  the  outside  of  the  tube,  and  are  then  joined,  when 
desired,  to  the  wires  coming  from  the  static  machine  or  the  coil.  The 
positive  wire  should  be  connected  with  the  target ;  the  negative  with  the 
cathode.  A  tube  should  always  be  in  shunt  circuit,  and  to  avoid  as 
far  as  possible  any  danger  of  puncturing  it  the  spark-gap  between  the 


42       THE    ROENTGEN   RAYS   IN    MEDICINE   AND   SURGERY 

terminals  of  the  coil  should  only  be  long  enough  to  prevent  the  dis- 
charge from  passing  between  them  instead  of  going  through  the 
tube. 

Resistance  of  the  Tube.  —  All  vacuum  tubes,  even  when  similar  in 
construction,  do  not  allow  the  electric  current  to  pass  through  them 
with  equal  ease.  When  the  current  passes  easily  the  tube  is  said  to 
have  a  low  resistance  ;  when  it  passes  with  difficulty  or  not  at  all,  a  high 
resistance.  When  a  tube  has  been  used  for  some  time  its  resistance  is 
increased,  and  finally  becomes  such  that  the  current  will  no  longer  pass 
through  it.  Rollins  ^  believes  that  this  increase  in  resistance  is  partly  due 
to  the  removal  of  the  gas  from  the  terminals  and  its  absorption  by  the 
glass  walls  of  the  tube. 

High  and  Low  Resistance  Relative  Terms.  —  But  the  terms  high  and 
low  resistance  are  only  relative,  because  the  resistance  in  a  tube  that 
was  low  for  one  form  of  apparatus  might  be  too  high  for  other  forms. 
Tubes  of  lower  resistance  may  be  used  on  static  machines  than  on  some 
coils.  For  instance,  I  have  observed  that  the  tubes  which  have  been 
used  on  my  large  static  machine  until  their  resistance  is  too  high  for  it, 
are  then  just  right  for  my  coil.  Thus  a  tube  which  is  too  high  for  a 
static  machine  may  be  right  for  a  coil,  but  this  depends  on  the  kind  of 
coil  and  the  current  used. 

Method  of  measuring  Resistance  by  Means  of  Spark-Gap.  —  The 
amount  of  obstacle  to  the  passage  of  the  current  through  the  tube,  or 
in  other  words,  the  resistance  of  the  tube,  may  be  readily  measured  by 
finding  out  through  how  long  a  distance  in  the  air  the  electric  current 
will  jump  rather  than  go  through  the  tube.  This  amount  may  be 
roughly  estimated  as  follows :  With  the  static  machine,  tube,  etc., 
arranged  as  in  Fig.  37,  the  spark-gap  in  the  series  with  the  tube  being 
closed,  the  operator  places  one  end  of  a  curved  metal  rod  which  is 
fixed  into  an  insulated  handle,  in  contact  with  one  of  the  wires  con- 
necting the  static  machine  with  the  wire  of  the  vacuum  tube,  and 
approaches  the  other  end  toward  the  second  wire  connecting  the  static 
machine  with  the  other  wire  of  the  tube.  A  point  is  thus  soon  found 
at  which  the  current  prefers  to  go  from  the  static  machine  wire,  through 
the  rod,  and  then  jump  across  more  or  less  air  space  to  the  other  static 
machine  wire  at  B,  rather  than  go  through  the  tube.  If  the  resistance 
is  high  the  current  will  jump  across  20  or  more  centimetres  rather  than 

1  Rollins  has  discussed  this  and  other  important  points  .relating  to  tubes,  in  articles  pub- 
lished in  the  Electrical  Revieiv,  during  1897-1898-1899-1900. 


X-RAY    EQUIPMENT  43 

go  through  the  tube.  If,  on  the  other  hand,  it  is  low,  the  current  will 
go  through  the  tube  rather  than  jump  an  air  space  of  a  millimetre  or 
less.  The  amount  of  obstacle  to  the  passage  of  the  current,  then,  may- 
be indicated  by  saying  that  the  tube  has  a  resistance  of  so  and  so  many 


Fig.  37.     Cut  showing  method  of  determining  the  resistance  of  the  tube. 

The  current  jumps  across  the  air  space  at  B  rather  than  go  through  the  tube.  When  the  resist- 
ance of  the  tube  is  low,  the  current  will  pass  through  the  tube  even  when  the  distance  at  i5  is  a  milli- 
metre or  less.  When  it  is  high  it  will  jump  across  the  air  space  at  B,  even  when  the  distance  is 
13  centimetres  (about  5  inches)  or  more. 

centimetres  or  millimetres.  This  means  of  measurement  is  equally 
applicable  to  a  coil,  but  is  carried  out  a  little  differently ;  the  two 
terminals  of  the  coil  take  the  place  of  the  two  wires  connecting  the 
static  machine  with  the  tube,  and  the  rod  may  be  straight  instead  of 
curved. 


44       THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Methods  for  changing  Resistance 

Low  Resistance. —  If  the  resistance  becomes  much  too  low  it  is  best 
to  send  the  tube  back  to  the  maker  to  be  repumped,  because  the  process 
of  raising  the  resistance  by  running  it  on  a  machine  of  ordinary  power 
is  a  very  long  one.  It  should  be  understood  that  a  new  tube  which 
gives  satisfactory  light  on  a  machine  of  moderate  capacity  may  become 
too  low  in  resistance  if  run  for  a  few  moments  on  a  very  large  machine, 
because  gas  is  driven  out  of  the  terminals  into  the  tube. 

High  Resistance.  —  If  the  resistance  is  too  high  it  may  be  lowered 
in  the  following  ways  :  — 

I.  By  the  introduction  of  gas  from  an  auxiliary  bulb,  (a)  By  an 
au.xiliary  bulb  containing  potash.  This  bulb  may  be  heated  by  means 
of  a  lamp ;  a  certain  amount  of  vapor  is  thus  driven  out  of  the  potash 
into  the  tube.  The  tube  in  which  this  ingenious  device  is  employed 
was  invented  by  Crookes  and  has  been  adopted  and  modified  by  Sayen 
and  others. 

Scjjrn's  Tube}  —  The  regulator  used  on  this  tube  consists  of  a  small 
bulb  which  contains  a  chemical  that  gives  off  vapor  on  being  heated  and 
reabsorbs  it  when  cooled,  and  is  connected  directly  with  the  vacuum 
tube  and  surrounded  by  an  auxiliary  tube  that  is  exhausted  to  a  low 
Crookes  vacuum.  The  cathode  in  the  auxiliary  tube  is  opposite  the 
above-mentioned  bulb,  so  that  any  discharge  through  this  tube  will 
heat  the  bulb.  This  cathode  is  connected  with  an  adjustable  spark- 
point  which  may  be  set  at  any  desired  distance  from  the  cathode  in  the 
main  tube.  When  the  resistance  of  the  latter  is  high,  the  current  goes 
through  the  auxiliary  tube  and  thus  heats  the  chemical  in  the  small 
bulb  until  a  sufficient  amount  of  vapor  has  been  driven  into  the  main 
tube  to  make  that  the  path  of  least  resistance.  The  resistance,  by 
means  of  the  regulator,  may  be  varied  by  placing  the  spark-point  at 
a  considerable  distance  from  or  close  to  the  cathode  of  the  main  tube. 
This  method  is  an  excellent  one  for  automatically  regulating  the  resist- 
ance, and  enables  the  operator  to  use  the  same  tube  and  yet  have  the  resist- 
ance high  or  low  as  he  desires.     The  tubes  are  made  in  Philadelphia. 

{b)  By  an  auxiliary  bulb  containing  other  chemicals.  Rollins  has 
devised  regulators  which  are  operated  either  by  heating  the  bulb  or  by 
passing  an  electric  current  through  it,  oxygen,  nitrogen,  or  hydrogen 
being  thus  liberated,  according  to  the  chemical  used. 

1  Electrical  Revieiv,  New  York,  May  12,  1897,  P-  226. 


X-RAY    EQUIPMENT 


45 


2.  By  the  liberation  of  gas  from  the  terminals.  If  the  tube  is  new 
and  a  powerful  machine  is  used,  the  gas  may  be  set  free  from  the 
terminals  by  driving  an  electric  current  through  the  tube. 


Fig.  38.    A.  W.  L.  X-light  tube  with  a  rotary,  sliding  target  and  an  automatic  regulator  (Rollins). 

This  regulator  R  can  be  used  to  lower  permanently  the  high  resistance  of  the  tube  or  to  vary  the 
resistance  as  the  examination  proceeds.  The  resistance  can  be  temporarily  lowered  by  pushing  in  the 
rod,  seen  on  the  upper  part  of  the  cut, and  raised  again  by  drawing  it  out.  This  regulation  of  the  resist- 
ance is  accomplished  by  means  of  a  substance,  placed  in  the  arms  of  the  cross,  that  is  mixed  with  a 
conducting  powder.  In  this  mixture  a  great  number  of  spark-gaps  are  formed  and  gas  is  liberated  when 
the  electric  current  passes,  and  absorbed  when  it  ceases.  The  resistance  may  be  permanently 
lowered  by  heating  the  head  of  the  cross,  as  this  head  contains  a  substance  which  liberates  gas,  when 
heat  is  applied  to  it,  that  is  not  reabsorbed. 


3.  By  the  liberation  of  gas  from  the  walls  of  the  tube.  This  may 
be  accomplished  by  baking  the  tube  in  an  oven  at  about  500°  F.,  (see 
Fig-  35  5>  chapter  on  Dental  Surgery),  or  by  enclosing  it  in  a  box  contain- 
ing incandescent  lamps,  or  by  holding  a  lamp  beneath  the  tube  while  it  is 
turned,  care  being  taken  in  the  latter  case  to  avoid  cracking  the  tube. 

All  regulators  appear  finally  to  fail  in  their  effects,  for  when  the 
resistance  has  been  lowered  by  them  a  number  of  times  the  tubes 
require  more  energy  to  run  them  than  when  they  were  new,  and  the 
quality  of  light  is  not  as  good  as  that  given  off  by  a  new  tube. 

The  length  of  time  a  tube  may  be  run  without  using  the  regulator  or 
repumping  depends  largely  upon  the  amount  of  energy  sent  through  it. 
A  tube  may  be  run  on  my  large  static  machine  at  the  Boston  City 
Hospital,  and  give  a  perfectly  steady  and  excellent  light  for  twelve  or 
more  hours  without  a  moment's  interruption.  It  can  be  used  for  the 
examination  of  patients  in  periods  which  add  up  to  a  total  of  at  least 
eighteen  hours  before  the  regulator  is  required,  but  every  time  thereafter 
that  the  regulator  is  employed,  the  intervals  between  its  periods  of 
service  become  somewhat  shorter,  until  finally  repumping  is  necessary. 


46     thp:  roentgen  rays  in  medicine  and  surgery 

Quality  of  Light— The  penetrating  power  of  any  given  quality  of 
light  depends  upon  its  amount.  With  a  tube  of  high  resistance  the 
power  of  penetration  is  greater,  but  the  differentiation  of  tissues  is  not 
as  marked,  as  with  light  from  a  tube  with  lower  resistance. 

A  simple  way  of  testing  the  quality  of  the  light  is  to  examine  the 
hand  with  the  fluorescent  screen.  If  the  resistance  is  high  the  bones 
will  be  nearly  as  light  as  the  flesh ;  if  the  resistance  is  low,  the  bones 
will  be  a  little  darker  absolutely  and  also  darker  relatively.  The  light 
is  good,  especially  for  taking  radiographs,  when  such  a  picture  of  the 
hand  as  is  shown  in  Fig.  39  is  seen  on  the  fluoroscope  at  the  distance  of 
half  a  metre  from  the  tube,  and  shows  little  difference  in  the  quality, 
at  more  than  double  this  distance. 

Suitable  Term  for  defining  Character  of  Tube.  —  Instead  of  speaking  of 
tubes  of  high  and  low  vacuum,  or  hard  and  soft  tubes,  I  think  it  is 
better  to  define  the  character  of  the  tube  by  its  air  resistance ;  that  is 
to  say,  when  specifying  the  kind  of  tube  that  is  most  suitable  for 
a  given  purpose,  to  state  that  its  air  resistance  is  equal  to  i,  2,  or 
more  centimetres,  as  the  case  may  be,  because  it  is  impossible  by  any 
means  at  present  known  to  determine  accurately  the  degree  of  the 
vacuum. 

Resistance  of  Tube  for  Fluorescent  Screen  and  Radiograph.  —  For 
work  with  the  fluorescent  screen,  or  for  photography,  the  tube  should 
be  such  as  will  give  the  greatest  differentiation  possible  between  the 
tissues.  When  a  static  machine  —  which  is  capable  of  maintaining  a 
great  difference  of  potential  between  the  terminals,  35  centimetres  or 
more  —  is  used,  the  resistance  of  the  tube  may  be  i  millimetre  only,  and 
yet  by  using  a  multiple  spark-gap  the  best  conditions  for  seeing  may 
be  produced.  The  advantage  of  such  a  tube  is  that  it  can  be  used  longer 
before  its  resistance  is  so  increased  by  use  that  it  is  necessary  to  lower 
it  than  when  it  is  received  from  the  maker  with  a  high  resistance.  One 
cause  of  this  high  resistance,  as  indicated  above,  is  the  more  thorough 
removal  of  gas  from  the  terminals,  and  therefore  the  life  of  the  tube  is 
shorter,  for  Rollins  states  that  it  is  on  the  supply  of  gas  in  them  that 
we  partly  depend  for  the  X-rays. 

For  many  coils,  however,  it  is  desirable  to  use  a  tube  with  a  higher 
resistance  —  about  6  to  10  centimetres  —  because  the  greater  amount  of 
current  which  the  coil  sends  through  the  tube  liberates  gas  rapidly,  with 
the  result  that  the  resistance  is  lowered  quickly  to  such  a  point  that  the 
tube  becomes  unfit  for  use. 


X-RAY    EQUIPMENT  47 

Amount  of  Light  necessary  for  Photograph  and  Screen.  —  For  taking 
radiographs  a  stronger  light  is  required  than  when  the  fluorescent 
screen  is  used,  because  when  the  latter  is  employed  the  current  can  be 
economized  by  sending  it  in  less  frequent  discharges  ;  the  light  will 
appear  continuous  to  the  eye  if  the  interruptions  are  1200  per  minute; 
but  for  photography  the  discharges  must  be  larger  in  amount  and  more 
rapid,  in  order  to  get  the  best  results  in  a  reasonable  time.  Coils,  as 
a  rule,  take  radiographs  more  quickly  than  static  machines. 

Effect  of  the  Resistance  of  the  Tube  on  the  X-Ray  Picture  thrown  on 
the  Screen,  and  the  Advantage  of  the  Multiple  Spark-Gap.  —  The  follow- 
ing diagram  is  taken  from  an  article  by  Robert  Kienbock.^  It  is  used 
by  him  to  illustrate  the  effect  of  the  resistance  of  the  tube  on  the  pic- 
ture produced  on  the  screen,  and  also  to  show  that  in  certain  degrees  of 
resistance  no  picture  is  produced.  I  insert  it  here  for  the  same  purpose, 
and  also  to  indicate  the  advantage  of  the  multiple  spark-gap. 

Forms  of  Tubes.  —  The  most  satisfactory  tubes,  both  for  static 
machines  and  coils,  that  I  have  used,  are  made  in  accordance  with 
the  directions  of  Dr.  Rollins. 

The  question  of  vacuum  tubes  has  been  considered  at  some  length 
because  so  much  depends  upon  the  tube.  It  is  neither  necessary  nor 
desirable,  however,  that  every  one  using  the  X-ray  apparatus  should 
have  all  varieties  of  tubes. 

Aluminum  Screen.  —  This  screen  is  interposed  between  the  tube  and 
the  patient,  and  grounded  as  recommended  by  Tesla  for  the  protection 
of  the  patient.     (See  Fig.  47.) 

Tube  Holder.  —  It  is  sometimes  an  advantage,  during  an  examination 
with  the  fluorescent  screen,  to  move  the  vacuum  tube,  for  by  this  means 
the  position  of  the  shadow  of  the  object  examined  is  altered,  the  given 
object  is  seen  from  more  than  one  point  of  view,  and  thus  additional 
information  is  obtained.  Figure  40  shows  a  tube  holder  which  I  devised 
in  1896  for  accomplishing  this  purpose.  It  consists  of  a  wooden  up- 
right, on  a  base,  which  carries  a  horizontal  wooden  rod  that  supports  the 
vacuum  tube,  and  can  be  moved  into  any  desired  position,  up  or  down, 
or  from  side  to  side. 

Diaphragm.  —  The  electric  currents  used  to  excite  the  vacuum  tube 
are  not  perfectly  unidirectional,  and  at  times  the  whole  of  the  tube  may 
become  a  source  of  X-rays  instead  of  a  small  point  on  the  target  only ; 

1  "  Ueber  die  Einwirkung  des  Rontgen-Lichtes  auf  die  Haut,"  Wien.  klin.  Woch., 
Dec    13,   1900,   1153-1166. 


48       THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


No  light. 


-^ 


No  light,  without  spark-gap. 


Fig.  39.  Diagram  showing  the  effect  of  the  resistance  of  the  tube  on  the  X-ray  picture  thrown 
on  the  screen  and  the  advantage  of  the  multiple  spark-gap.  The  direction  of  the  light  is  down- 
wards and  to  the  left. 

No.  I.  The  current  does  not  pass  through  this  tube,  as  the  resistance  is  very  high  (a  tube 
of  such  high  resistance  maybe  easily  punctured).  The  amount  of  this  resistance  can  be  ascer- 
tained by  measuring  its  equivalent  of  air  resistance,  as  described  on  p.  43. 

No.  2.  The  resistance  of  the  tube  is  high;  the  picture  of  the  hand  on  the  screen  is  bright,  but 
without  contrast. 

No.  3.  The  resistance  of  this  tube  is  not  so  high  as  in  No.  2.  The  picture  of  the  hand  is  a  good 
one,  with  well-marked  contrast  between  the  bones  and  fiesh. 


X-RAY   EQUIPMENT 


49 


No.  4.  The  resistance  of  this  tube  is  low ;  the  picture  of  the  hand  on  the  screen  is  dark,  and  the 
contrast  between  the  flesh  and  the  bones  is  not  marked.  By  using  a  multiple  spark-gap,  described 
on  p.  17,  with  the  tube  the  light  is  excellent  and  the  picture  becomes  like  that  seen  in  Fig.  3. 

No.  5.  The  resistance  of  this  tube  is  very  low,  about  one-half  a  millimetre,  but  by  using  more 
of  the  multiple  spark-gap  than  for  Xo.  4  the  light  becomes  good. 

The  light  which  gives  most  penetration  is  that  obtained  from  No.  2,  but  the  differentiation  of  the 
soft  tissues  is  not  accomplished  as  well  with  it  as  with  a  tube  of  lower  resistance.  In  order  to  increase 
the  penetrating  power  of  a  tube  with  lower  resistance,  more  energy  must  be  passed  through  it. 

From  what  has  been  stated  above,  it  will  be  seen  that  a  spark-gap  is  an  essential  part  of  every 
apparatus,  as  without  it  such  tubes  as  Nos.  4  and  5  are  useless,  but  with  its  aid  they  become  good 
tubes.  If  a  spark-gap  is  employed  with  the  X-ray  apparatus,  the  range  of  resistance  within  which 
a  tube  or  tubes  can  be  used  is  increased,  and  thereby  the  life  of  the  tube  is  lengthened. 

second,  the  practitioner  may  desire  to  expose  a  small  surface  to  the 
rays ;  in  either  of  these  cases  the  rays  may  be  prevented  from  passing 
into  the  room  in  the  direction  of  the  patient,  except  where  desired,  by 
the  use  of  a  diaphragm,  which  consists  of  a  sheet  of  lead  in  which  a 


FlO.  40.     Tube  holder. 

This  cut  is  taken  from  my  article,  "A  Study  of  the  Adaptation  of  the  X-Rays  to  Medical  Prac- 
tice," in  the  Medical  and  Surgical  Report  of  the  Boston  City  Hospital,  for  January,  1897,  and  shows  a 
tube  holder  and  two  kinds  of  diaphragms  devised  by  me  in  1896. 

When  it  was  desired  to  darken  the  room  absolutely,  the  light  from  the  tube  was  shut  out  by 
means  of  a  cover  made  of  thin  black  fibre.  (Cover  not  shown  in  cut.)  Dark  cloth  or  velvet  could 
also  be  used  for  this  purpose. 


hole  has  been  cut.  The  diaphragm  should  be  near  the  tube,  and  the 
hole  as  small  as  will  allow  a  cone  of  rays  to  pass  of  sufficient  size  to 
cover  the  area  to  be  examined.  Figure  40  shows  a  diaphragm,  which 
I  used  at  this  time,  in  position  for  service.     The  pieces  of  wood  seen 

E 


50       THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

on  either  side  of  the  vacuum  tube  are  grooved,  and  into  these  grooves 
the  diaphragm  is  slid.  As  a  protection  to  the  observer,  sheets  of  lead 
were  fastened  outside  these  wooden  side  pieces,  to  cut  off  the  rays  com- 
ing in  his  direction.  Now  that  tubes  of  lower  resistance  are  used  than 
formerly,  the  lead  plates  forming  the  diaphragm,  and  those  opposite 
the  sides  of  the  bulb,  can  well  be  wider,  and  thus  the  X-rays  except 
those  coming  through  the  opening  of  the  diaphragm  and  from  either 
end,  can  be  shut  out. 

Hand  Diaphragm.  —  The  picture  on  the  fluorescent  screen  may  be 
more  clearly  seen  by  the  use  of  a  special  diaphragm  the  opening  of 
which  may  be  circular  or  rectangular,  as  desired.  Figure  40  shows  one 
of  several  of  the  latter  kind  lying  on  the  base  of  the  tube  holder. 
The  fingers  should  be  protected  from  the  rays  while  holding  the 
sheet  of  metal,  and  to  accomplish  this  purpose  leather  straps  are 
fastened  to  the  metal  so  that  the  fingers  may  be  inserted  under 
them  on  the  upper  side.  The  diaphragm  may  be  moved  about 
and  any  special  part  examined.  After  the  observer  has  taken  a  general 
survey  with  the  fluorescent  screen,  the  part  of  the  body  that  is  to  be 
carefully  examined  is  selected,  and  the  metal  plate  held  under  and 
against  the  stretcher  in  such  a  position  that  the  X-rays  fall  directly 
through  the  opening,  while  they  are  cut  off  from  the  surrounding  area. 

2.  A  larger  tube  holder  which  I  have  dexdsed  and  found  to  answer 
very  well,  and  which  may  be  made  by  any  carpenter,  consists  of  a  wooden 
upright  213  centimetres  (7  feet)  high,  mounted  on  a  base  having  three 
castors.  The  arm  which  carries  the  vacuum  tube  is  joined  to  a  piece 
of  wood  that  slides  up  or  down  on  the  upright,  the  counterpoise  and 
arm  being  connected  by  a  cord  going  over  a  pulley  at  the  top  of  the 
upright ;  the  arm  is  fastened  to  the  upright  by  a  wooden  pin  that  per- 
mits a  hinge-like  motion,  and  allows  the  arm  to  swing  parallel  with  the 
floor.  By  this  means  the  tube  may  be  placed  in  any  desired  position, 
either  above  or  below  the  patient,  with  the  face  of  the  target  directly 
opposite  the  patient. 

3.  A  more  complete  tube  holder  is  one  devised  by  Dr.  Rollins.  It 
consists  of  an  upright  brass  tube,  inside  of  which  is  a  leaden  counter- 
poise for  the  arm  carrying  the  vacuum  tube.  The  tube,  as  in  the  other 
tube  holders,  may  be  adjusted  to  any  position.     (See  Fig.  41.) 

Box  for  Tube.  —  The  tube  is  held  in  a  box  with  a  sliding  cover 
which  Dr.  RoUins  has  had  made  for  me,  painted  on  the  inside  with 
many  coats  of  white  lead,  in  which  a  hole  five  centimetres  in  diameter 


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52 


THE    ROKNTGEN    RAYS    IN    MEDICINE   AND    SURGERY 


has  been  cut.  Comparatively  few  rays  can  escape  from  this  box 
except  through  the  hole.  A  circular  diaphragm  made  of  wood  and 
coated  with  white  lead,  like  the  box,  fits    over    the    circular    opening. 


Fig.  42.     Cooled  target  tube  in  box  with  cover  removed.     (Rollins.) 

Detail  of  tube  box.  The  terminal  wires  are  not  attached  to  the  terminals  of  the  tube,  as  this 
might  endanger  the  tube.  They  are  held  firmly  in  taper  plugs  in  hard  rubber  insulating  plates  at 
each  end  of  the  tube  box,  and  simply  rest  in  contact  with  the  tube  terminals.  CC,  supports  for  tube ; 
DD,  clamps  for  tube;  E,  inlet  tube  for  cooling  water;  /",  outlet  tube  for  cooling  water;  BB,  bars  to 
allow  CC,  the  supports,  to  slide  for  the  purpose  of  adjusting  their  position  for  different  tubes. 

This  diaphragm  has  three  round   holes   of    different   sizes,  the  largest 
corresponding  in  size  to  the  hole  in  the  box,  and  is  fastened  in  such  a 


Fig.  43.     This  cut  shows  the  box  devised  by  Ur.  Rollins,  with  some  slight  modifications  which  I 

have  made. 
This  box  has  a  hinged  instead  ot  a  sliding  cover.  It  has  also  a  sliding  diaphragm.  Lines  are 
marked  on  the  inside  of  the  box,  on  either  side  of  the  hole  cut  in  the  cover  and  on  the  bottom.  The 
target  of  the  lube  should  be  placed  opposite  these  lines.  Corresponding  lines  are  likewise  marked 
on  the  outside  of  the  cover  (see  Fig.  45),  to  indicate  to  the  practitioner  the  position  of  the  target  when 
the  box  is  closed.  When  one  tube  is  changed  for  another,  the  connection  of  the  new  tube  with  the 
terminals  may  be  readily  made  by  means  of  the  device  at  A,  which  is  shown  in  detail  in  Fig.  44. 


X-RAY    EQUIPMENT 


53 


way  to  the  box,  when  in  use,  that  it  can  be  turned,  and  thus  the  desired 
aperture  can  be  brought  opposite  the  opening  in  the  box.     It  should 


Fig.  44.     B  is  a  vulcanite  plug  in  which  four  longitudinal  cuts  have  been  made  reaching  half  its 
length,  and  carries  the  insulated  wire  A. 

When  B  is  pushed  into  place,  the  wire  is  clamped  and  held  at  .r/.  D  is  a.  brass  ball  1.25  cm.  in 
diameter,  which  is  soldered  to  the  insulated  copper  wire  A,  and  on  its  opposite  side  has  a  cone- 
shaped  hole  bored  out  of  it,  which  fits  over  the  wire  terminal  on  the  outside  of  the  tube. 

be  remembered  in  choosing  this  aperture  that  the  diameter  of  the  cone 
of  rays  increases  with  its  distance  from  the  tube.  (See  cliapter  on 
Therapeutic  Uses,  page  400.) 


^■;^^^^^^^^^^^^^V 


Fig.  45.     The  same  box  as  shown  in  Fig.  43,  with  cover  closed.     The  thin  aluminum  screen  15  cm. 
wide  which  fits  across  and  close  to  the  cover  over  the  circular  opening  is  not  shown. 


Aliiuiijuiui  Screen  and  Diaphragm.  —  I  have  devised  an  aluminum 
screen  and  diaphragm  combined,  to  be  used  with  this  box,  which  is 
placed  over  the  circular  diaphragm  just  described,  and  grounded.  This 
screen  has  one  hole  in  it  corresponding  in  size  to  the  largest  hole  in 


54        THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

the  circular  diaphragm  and  the  box,  and  can  be  turned  so  that  its 
opening  coincides  with  their  largest  one  ;  while  the  screen  is  in  this 
position  the  proper  place  for  the  target  is  found  by  means  of  the  light 
issuing  from  the  tube  through  this  hole.  The  screen  is  then  turned 
until  its  solid  portion  is  brought  over  the  aperture  in  the  box  and  circular 
diaphragm  in  order  that  the  room  may  be  perfectly  dark  while  the 
examination  with  the  fluorescent  screen  is  being  made. 


Fig.  46.    Tube  holder  open. 

This  tube  holder  (Fig.  46)  consists  of  a  box,  the  upper  and  lower  parts  of  which  are  of  equal  size  and 
are  hinged  together  at  the  back.  It  has  a  hole  cut  at  either  end  which  is  large  enough  for  the  stems  of 
the  tube,  which  protrude  somewhat,  to  go  through.  In  the  top,  front,  and  bottom  of  the  box,  which 
is  coated  inside  with  white  lead,  as  proposed  by  Dr.  Rollins,  are  three  circular  openings,  each  of 
which  is  6j  centimetres  in  diameter.  Over  each  of  these  above-mentioned  sides,  as  a  protection  from 
the  X-rays,  is  a  sheet  of  lead  2J  millimetres  thick,  which  slides  in  grooves.  When  it  is  desired  to  use 
a  given  opening,  the  sheet  of  lead  is  taken  out  and  another  sheet  of  lead,  perforated  with  a  circular 
hole  of  the  size  desired,  is  slid  into  place.  The  three  openings  are  made  in  order  that  the  tube  may 
be  used  above,  below,  or  in  front  of  the  patient  without  turning  the  box,  although  of  course  the  tube 
must  be  turned.     (See  also  Fig.  47  and  Appendix  for  more  recent  form  of  tube  holder.) 

Fluorescent  Screen 

This  screen  is  made  by  coating  one  side  of  a  piece  of  cardboard  with 
crystals  of  tungstate  of  calcium,  or  with  platino-cyanide  of  barium  ;  and 
great  care  must  be  exercised  in  making  it.  The  crystals  of  either  salt 
must  be  of  proper  size  and  spread  uniformly  in  a  layer  of  a  suitable 
thickness  over  the  surface  of  the  cardboard.  The  tungstate  of  calcium 
is  white,  and  the  light  is  more  suitable  for  many  purposes  than  the  more 
brilliant  though  slightly  colored  fluorescence  obtained  from  the  platino- 


X-RAY   EQUIPMENT 


55 


cyanide  of  barium.  Screens  of  the  latter  kind  are  less  durable  than 
others  ;  they  are  injured  by  pressure,  and  should  not  be  kept  in  a  warm 
room  ;  but  each  kind  has  its  respective  uses. 

Tungstate  of  Calcium  Screen.  —  Certain  of  the  tungstate  of  calcium 
screens  are  phosphorescent  as  well  as  fluorescent  —  that  is,  in  a  dark 
room  they  retain  the  image  of  an  object  opaque  to  the  rays  for  a  moment 
after  the  tube  has  been  shut  off.  They  should  therefore  be  tested  in 
the  following  way  before  being  purchased  :  — 

After  the  physician  has  been  long  enough  in  the  dark  room  to 
get  his  eyes  into  condition  to  see  the  fluorescence,  the  vacuum  tube 
should  be  excited  and  the  light  from  it  should  be  excluded  by  covering 


Kk;.  47.     Tube  holder  closed  and  ready  for  use. 

the  tube  with  a  dark  cloth,  or  by  placing  it  in  the  box  already  described. 
A  piece  of  heavy  metal  should  then  be  placed  under  the  fluorescent 
screen  and  held  in  the  same  position  for  a  minute  or  two.  While  the 
physician  is  thus  observing  the  screen,  the  current  should  be  shut  off 
from  the  tube.  If  the  screen  has  simply  fluorescent  properties  it  will 
instantly  become  dark,  but  if  the  part  protected  by  the  metal  remains 
dark,  and  the  other  portions  retain  any  brightness,  the  screen  has  phos- 
phorescent as  well  as  fluorescent  properties,  and  should  be  discarded. 
Mr.  T.  B.  Kinraide,  of  the  Spring  Park  Laboratory,  Boston,  Mass.,  has 
succeeded,  by  his  careful  and  laborious  investigation,  in  making  tung- 


56       THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

state  of  calcium  screens  that  are  without  phosphorescence.  They  are 
very  satisfactory,  and  I  prefer  them  to  any  others  that  I  have  used. 

Tungstate  of  Calcium  Screen  better  for  Examinations  of  the  Thorax 
than  Platino-Cyanide  of  Barium.  —  For  examinations  of  the  heart  and 
kmgs  the  character  of  the  light  from  the  tungstate  of  calcium  screen  is 
more  satisfactory  than  that  from  the  platino-cyanide  of  barium. 

Platino-Cyanide  of  Barium  Screen.  —  The  platino-cyanide  of  barium 
screens  which  I  had  from  Kahlbaum  of  Berlin  were  not  as  good  as  those 
I  obtained  in  the  United  States  from  Aylesworth  &  Jackson  (now 
Francis  E.  Jackson)  of  Orange,  N.  J.  The  first  screens  made  by  the 
latter  firm  deteriorated  rapidly,  but  this  difficulty  has  been  partially 
overcome  by  them,  and  probably  also  by  Kahlbaum. 

Size  of  Screen.  — The  screen  for  examining  the  thorax  should  be  at 
least  25x30,  or,  still  better,  30x35  centimetres,  so  that  both  sides  of 
the  chest  may  be  seen  at  once  and  thus  be  readily  compared  ;  for  ordinary 
uses  20x25  centimetres.  For  examination  of  the  neck  a  screen  small 
enough  to  go  between  the  clavicle  and  the  jaw  is  necessary. 

Sheet  of  Glass  or  Film  of  Celluloid.  —  A  thin  sheet  of  glass  or  a  film 
of  celluloid  may  be  placed  over  the  surface  of  the  screen,  upon  which 
the  outlines  seen  during  an  examination  may  be  traced  with  a  pencil. 
When  glass  is  used  the  lines  may  be  drawn  with  an  ordinary  pencil,  if 
the  glass  is  ground ;  if,  on  the  other  hand,  the  celluloid  is  used,  or  clear 
glass,  a  lithographer's  pencil  is  necessary.     (See  Chapter  III.) 

Fluoroscope 

The  fluoroscope  is  a  pyramidal  truncated  box,  the  base  of  which  is 
formed  by  the  fluorescent  screen  and  the  top  of  which  has  an  opening 
which  fits  over  the  eyes  in  a  way  to  exclude  the  light  from  the  room. 
(See  Chapter  III,  Fig.  61.) 

Comparison  of  Fluorescent  Screen  and  Fluoroscope.  —  The  fluoroscope, 
shown  in  Chapter  III,  Fig.  61,  is  a  very  convenient  form  of  apparatus, 
but  usually  I  prefer  to  make  X-ray  examinations  of  the  chest  with  an 
open  screen,  the  edges  of  which  are  strengthened  by  a  frame.  (See 
Chapter  III,  Fig.  59.) 

Photographic  Plate 

The  general  rules  of  photography  apply  in  developing,  fixing,  and 
preserving  the  X-ray  negatives,  and  therefore  only  a  few  suggestions 
will  be  given  here. 


X-RAY    EQUIPMENT  57 

Make  of  Plate.  —  Any  quick  plate  which  is  the  product  of  a  good 
maker,  and  not  too  old,  may  be  used.  Those  made  in  this  country  are, 
I  beUeve,  as  good  as  any.  The  Carbutt,  Seed,  Cramer,  Hammer,  and 
Stanley  plates  are  satisfactory. 

Protection  of  Plate.  —  It  is  well  to  keep  the  photographic  plates  else- 
where than  in  the  X-ray  room,  and  while  temporarily  in  this  room  they 
should  be  kept  in  a  box  made  of  lead  6  milhmetres  thick,  and  placed  as 
far  as  possible  from  the  vacuum  tube,  and  be  brought  out  when  it  is 
time  to  use  them.  The  plate  immediately  prior  to  its  exposure  should 
be  put  into  two  light-proof  envelopes  —  plates  deteriorate  if  kept  for  a 
long  time  in  these  envelopes  —  and  directly  after  the  exposure  it  is  wise 
to  put  it  again  into  the  lead  box  ;  for  if  the  vacuum  tube  should  hap- 
pen to  be  excited  when  the  plate  was  not  thus  protected  it  would  be 
spoiled.  The  plate  must  be  protected  from  moist  substances  or  from  a 
patient  who  perspires  freely,  and  this  protection  can  be  effected  by 
wrapping  the  plate  in  a  thin  sheet  of  rubber  or  in  a  paper  envelope 
thinly  coated  with  shellac. 

Photographic  Paper.  —  Any  photographic  paper  may  be  used  for 
printing  the  X-ray  negatives.  The  Velox  gives  good  detail  and  needs 
only  very  short  exposure  to  artificial  light.  After  the  Velox  prints  are 
mounted  nothing  should  be  allowed  to  touch  the  surface  until  the  print 
is  dry. 

Bromide  Paper.  —  If  an  X-ray  picture  is  desired  very  quickly,  bro- 
mide paper  in  light-proof  envelopes  may  be  used  instead  of  a  plate,  and 
developed  as  an  ordinary  negative  would  be,  —  bromide  paper  re- 
quires a  longer  exposure  than  a  plate;  —  by  this  means  it  is  quite 
practicable  to  obtain  an  X-ray  picture  within  an  hour.  One  or  more 
pieces  of  bromide  paper  may  be  exposed  at  the  same  time,  and  thus  the 
likelihood  of  getting  one  good  picture  is  increased.  Fig.  248,  in  the 
chapter  on  Fractures,  was  made  in  this  way. 

Development  of  Films.  —  Slow  development  gives  the  most  certain 
results.  A  good  length  of  time  is  15  minutes,  with  the  solution  at  a 
temperature  of  71°  F. 

Developer.  —  A  good  developer  is  made  as  follows  :  Water,  250  cubic 
centimetres  ;  metol,  0.5  ;  dry  carbonate  of  soda,  0.25  ;  sulphite  of  soda, 
5.  The  water  should  be  pure  and  the  chemicals  pure  and  dry.  Fresh 
developer  should  always  be  used. 

Test  of  Light  for  Development.  —  The  light  from  the  developing 
lamp  may  be  tested  by  holding  a  film  30  centimetres  from  the  lamp  for 


58     thp:  roentgen  rays  in  medicine  and  surgery 

5  or  6  minutes.  If  the  film  shows  any  trace  of  an  image,  more  red 
paper  should  be  used  in  the  lamp,  as  the  slightest  fog  on  the  negative 
is  injurious  to  the  definition. 

Fixing  in  Hyposulphite  of  Soda  Solution.  —  The  usual  washing  in  water 
after  development  is  unnecessary  ;  the  plates  should  be  thoroughly  fixed. 

Washing  the  Negative.  —  When  the  negative  has  been  removed  from 
the  hyposulphite  of  soda,  it  should  be  placed  in  running  water  if  avail- 
able ;  if  not  it  must  be  washed  in  several  changes  of  water,  the  water 
being  kept  in  motion  by  gentle  rocking. 

Precautions  to  be  taken  when  using  X-Ray  Apparatus  and  making 
X-Ray  Examinations.  —  Instances  of  burns  resulting  from  X-ray  exami- 
nations have  occurred  in  the  early  days  of  the  use  of  the  X-rays,  before 
the  precautions  which  should  be  taken  were  generally  understood,  and 
when  the  vacuum  tube  was  placed  very  near  the  patient.  Now  there  is 
no  reason  for  anxiety  in  regard  to  any  ill  effects  from  these  examina- 
tions in  the  hands  of  experienced  persons.  The  tube  must  be  placed  at 
a  considerable  distance  from  the  patient,  enclosed  in  a  suitable  box,  and 
a  thin  aluminum  screen,  which  should  be  grounded  as  recommended  by 
Tesla,  should  be  interposed  between  the  tube  and  the  patient. 

Harmlessness  of  X-Ray  Examinations  if  Proper  Precautions  are 
Taken.  —  The  fact  that  several  thousand  of  X-ray  examinations  have 
been  made  at  the  Boston  City  Hospital  alone,  and  always  without  any 
unpleasant  results  following,  demonstrates  the  entire  harmlessness  of 
these  examinations  when  they  are  carried  out  with  proper  care. 

For  later  experience  with  X-ray  equipment,  see  Appendix. 


CHAPTER    III 

METHODS    FOR   MAKING    X-RAY    EXAMINATIONS    WITH    THE    FLUO- 
RESCENT SCREEN  AND  X-RAY  PHOTOGRAPH 

In  1896  I  saw  that  differences  could  be  distinguished  between 
health  and  disease  in  some  of  the  organs  in  the  body  by  means  of 
examinations  made  with  the  fluorescent  screen,  and  that,  in  order  to 
increase  the  value  of  these  examinations  in  diagnosis,  some  systematic 
method  of  procedure  must  be  adopted.  It  was  necessary  that  every 
examination  should  be  carried  out  with  a  clear  understanding  of  the 
importance  of  the  fundamental  principle  that  the  source  of  light  must 
be  in  definite  and  suitable  relation  to  the  part  to  be  studied.  With 
this  end  in  view  I  devised  the  method  of  examination  which  I  will 
presently  outline.  By  means  of  this  method,  variations  in  the  appear- 
ances obtaining  in  different  diseases  can  be  recognized  with  accuracy, 
and,  further,  after  a  number  of  observations  have  been  collected,  they 
can  be  compared,  their  differences  and  similarities  noted,  and  the  obser- 
vations interpreted  in  a  way  which  would  otherwise  be  impossible. 
The  accurate  observation  and  record  of  movements  of  organs,  espe- 
cially in  the  thorax,  could  only  be  accomplished  by  some  such  method. 
This  method  not  only  permits  a  ready  comparison  of  examinations 
made  at  different  times  by  the  same  physician,  but  enables  two  physi- 
cians living  in  different  cities  to  compare  the  appearances  seen  in  the 
same  patient  at  different  periods,  and  to  note  whether  changes  have  or 
have  not  taken  place.  In  devising  the  method  I  have  studied  efficiency 
and  simplicity. 

Support  of  Patient  during  X-Ray  Examination ;  Recumbent  Posi- 
tion.—  It  is  important  both  for  the  patient  and  the  physician  that  the 
position  of  the  patient  during  an  examination  should  be  a  comfortable 
one,  and  also  one  that  can  be  exactly  resumed  should,  subsequently,  a 
second  examination  be  needed.  Since  clothing  and  fabrics  of  various 
kinds  are  easily  penetrated  by  the  rays,  a  canvas  stretcher  affords  a 
simple,  convenient,  and  comfortable  means  of  supporting  a  patient,  being 

59 


6o       THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


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METHODS   OF    EXAMINATION 


6l 


equivalent  so  far  as  the  X-rays  are  concerned  to  suspension  in  mid-air. 
This  stretcher  should  be  51  centimetres  (20  inches)  wide  only  and  183 
centimetres  (6  feet)  long,  and  should  be  supported  about  4  feet  above 
the  floor  (see    Fig.  49  ).       A  low    chair  or    other    convenient  step  to 


62       THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

enable  the  patient  to  get  on  to  the  stretcher  easily  should  be  at  hand. 
The  height  and  horizontal  position  of  the  stretcher  facilitate  the  work 
of  examination,  and  if  it  is  desired  to  examine  the  patient  from  the 
side,  or  when  lying  on  his  face  or  back,  he  can  readily  turn  on  the 
stretcher.  The  stretcher  forms  an  equally  convenient  support  during 
either  screen  or  photographic  examination. 

Relative  Position  of  Patient,  Tube,  and  Screen  or  Plate.  —  It  is  to  be 
remembered  that  the  X-ray  picture  on  the  screen  or  photographic  plate 
is  of  the  nature  of  a  shadow  such  as  that  cast  by  an  opaque  substance 
on  a  flat  surface  by  candlelight.  The  following  considerations  must, 
therefore,  be  regarded  in  X-ray  work :  First,  the  shadow  will  always 
be  somewhat  larger  than  the  object  if  the  tube  is  not  properly  placed, 
but  the  enlargement  will  diminish  as  the  distance  between  object  and 
screen  diminishes,  and  as  that  betw^een  object  and  tube  increases.  If 
the  tube  is  90  centimetres  (3  feet)  away,  the  enlargement  of  a  small 
object  is  so  slight  that  it  may  be  neglected  ;  if,  however,  it  is  desired  to 
determine  the  diameter  of  a  large  object  without  error,  this  may  be  done 
by  fir.st  placing  the  tube  directly  under  one  border  and  marking  its 
position,  and  then  under  the  other  and  marking  that  (see  page  263). 

Second,  the  shape  of  the  shadow  will  depend  upon  the  angle  at 
which  the  rays  strike  the  screen  or  plate.  For  instance,  the  optical 
shadow  of  a  ball  is  oval  when  the  surface  on  which  the  shadow  falls 
is  not  perpendicular  to  the  rays  from  the  source  of  light.  Third,  the 
outline  of  the  shadow  of  an  object  will  also  vary  with  the  angle  at 
which  the  object  is  placed  relatively  to  the  screen  or  plate ;  for  example, 
the  optical  shadow  of  a  heart  would  vary  in  shape  in  accordance  with 
its  position  in  regard  to  either  of  them. 

Distance  of  the  Vacuum  Tube.  —  The  distance  of  the  tube  from  the 
photographic  plate  may  range  from  60  to  92  centimetres  (2  to  3 
feet),  according  to  the  apparatus  used  and  the  part  to  be  photographed ; 
but  it  should  always  be  at  a  considerable  distance  from  the  patient, 
both  on  account  of  the  patient  himself  and  also  for  the  effect  on  the 
picture.  Even  with  a  small  apparatus  the  tube  should  be  at  least  40 
centimetres  away.  Because  of  the  desirability  of  uniformity  of  place 
for  the  tube,  I  generally  put  it  at  a  fixed  distance  from  the  plate 
or  screen,  and  have  found,  as  a  rule,  for  my  static  machine,  that  of 
75  centimetres  the  best,  whatever  the  part  to  be  observed  or  photo- 
graphed, with  the  exception  of  the  abdomen,  pelvis,  and  hips.  Plates 
must  be   exposed   longer  when  the   tube   is   at   a  distance  than   when 


METHODS   OF   EXAMINATION 


63 


nearer,  because  the  amount  of  light  is  inversely  as  the  square  of  the 
distance,  but  the  difference  in  time  is  rarely  sufficient  to  cause  incon- 
venience to  the  patient.     When  speed  is  necessary,  thin  parts,  such  as 


the  hand,  may  be  clearly  and  more  quickly  photographed  with  the 
tube  at  half  this  distance.  Exceptions  may  also  be  made  in  favor 
of  shorter  distances  for  other  parts  when  the  condition  of  the  patient 
requires  haste.      But  varying  the  distance  of  the  tube   from  the  plate 


64        THE    ROENTGEN    RAYS    IN    MEDICINE    AND   SURGERY 

with  each  exposure  makes  another  point  to  be  considered  in  estimating 
the  proper  length  of  the  exposure ;  it  is,  therefore,  simpler  as  a  rule  to 
place  the  tube  at  the  same  distance  from  the  plate  for  a  given  apparatus. 

The  following  experiment  serves  to  illustrate  the  effect  on  the  pic- 
ture of  the  distance,  near  or  remote,  of  the  tube  from  the  screen  or 
photographic  plate,  and  from  the  object  examined  ;  also  of  the  distance, 
near  or  remote,  of  the  object  from  the  plate. 

Two  pieces  of  cork  .5  centimetre  thick  and  about  10  centimetres 
square,  were  taken,  and  a  line  ruled  diagonally  across  them.  They 
were  then  placed  upright  upon  a  table,  parallel  to  each  other,  and  2 
centimetres  apart,  while  eight  pins  of  the  same  size,  2.5  centimetres 
long,  were  inserted  horizontally  through  the  two  pieces  of  cork  along  the 
diagonal  line  at  such  intervals  that  the  first  pin  was  1.25  centimetres, 
and  the  last  pin  10  centimetres  above  the  table.  Four  photographs 
of  these  pins  were  taken  with  the  tube  at  a  distance  of  30,  45,  61, 
and  92  centimetres  respectively.  Figure  5 1  shows  the  relative  position 
of  the  tube,  pins,  and  plate.  It  will  be  seen  by  examining  the  cut  (see 
Fig.  52)  that  the  first  pin,  1.25  centimetres  from  the  plate,  was  clearly  out- 
lined in  all  four  radiographs,  but  most  so  where  the  tube  was  92  centi- 
metres from  the  plate.  The  pin  that  was  2.5  centimetres  (i")  from  the 
plate  was  not  clearly  defined  when  the  tube  was  30  centimetres  from 
the  plate,  whereas  the  pin  5  centimetres  (2")  from  the  plate  was  defined 
with  tolerable  sharpness  with  the  tube  92  centimetres  from  the  plate 
and  87  centimetres  from  the  pin.  The  pin  10  centimetres  (4")  from  the 
plate,  with  the  tube  at  a  distance  of  30  centimetres  from  the  plate,  was 
most  exaggerated  in  size  and  least  sharply  defined  of  all  the  pins  in  the 
four  photographs.  It  is  unnecessary  to  describe  the  cut  further,  as  it 
speaks  for  itself.  If  the  object  examined  has  a  length  greater  than 
the  length  of  the  pins  used  in  this  experiment,  of  course  the  error  would 
be  greater.  This  experiment  demonstrates  that  to  get  the  best  defini- 
tion and  to  prevent  exaggeration  in  the  size  of  the  object  that  is  to  be 
photographed,  or  observed  on  the  fluorescent  screen,  the  object  must 
be  near  and  the  tube  distant  from  the  plate  ;  and  that  the  nearer  the 
tube  to  the  plate  the  more  important  is  it  that  the  object  also  be  near 
the  plate. 

Position  of  Tube  and  Screen  or  Plate.  —  The  tube  should  be  so  placed 
that  the  rays  will  fall  as  perpendicularly  upon  the  screen  or  photographic 
plate  as  the  given  conditions  will  permit.  The  following  diagrams,  like 
the  cuts  of  the  pins  (see  Figs.  51  and  52),  direct  attention  to  the  effect 


METHODS   OF    EXAMINATION 


65 


on  the  picture  of  the  position  of  the  tube  and  plate  with  reference  to  the 
part  to  be  photographed,  or  examined  with  the  fluorescent  screen,  and 
likewise  point  out  the  importance  of  having  the  plate  as  nearly  as  pos- 


FlG.  51.    Cut  of  photograph  showing  relative  position  of  the  cork  containing  the  pins,  the  photo- 
graphic plate,  and  the  vacuum  tube  when  Fig.  52  was  taken. 

sible  at  right  angles  to  the  direction  of  the  rays  (see  Fig.  53).     The 

target  of  the  tube  should  be  directly  opposite  the  part  to  be  examined. 

Method  for  securing  a  Constant  Position  for  the  Target  in  Relation  to 


66       THIO    ROKNTGEN    RAVS    IN    MEDICINE    AND    SURGERY 

the  Patient.  — This  constant  position  is  of  primary  importance,  and  may 
be  obtained  in  the  following  way. 

PluDib-liiics. — ^The  stretcher  support  should  be  provided  with  two 
plumb-lines,  one  hanging  from  either  end  of  its  median  line  ;  or  if  the  floor 
of  the  room  is  uncarpeted  a  line  may  be  drawn  upon  it  parallel  with  this 
median  line.  The  stretcher  is  narrow  and  sinks  a  little  with  the  weight 
of  the  patient,  so  that  it  is  easy  to  place  him  in  the  middle  of  it  and  get 
his  median  line  directly  over  that  of  the  stretcher.  The  physician  must 
be  sure  that  the  patient  lies  perfectly  flat.  After  the  patient  is  comfort- 
ably placed  flat  on  his  back,  as  described,  a  cord  150  to  180  centimetres 
(5  or  6  feet)  long,  with  a  small  weight  on  either  end,  is  put  across 
his  chest  on  a  level  with  his  fourth  rib.  The  ends  of  this  line  will  hang 
down  on  either  side  and  form  a  second  pair  of  plumb-lines.  The  phy- 
sician then  sights  from  one  end  of  this  line  to  the  other,  and  from  end 
to  end  of  the  first  pair  of  plumb-lines  described,  and  places  the  target 
of  the  vacuum  tube  at  the  j)oint  where  a  line  drawn  between  the  first 
pair  of  plumb-lines  would  intersect  a  line  drawn  between  the  second 
pair  of  plumb-lines  (see  Fig.  48);  the  target  is  thus  brought  immediately 
under  the  point  where  the  median  line  of  the  body  crosses  a  line  joining 
the  fourth  ribs  on  the  front  of  the  chest,  and  secures  for  the  tube  a 
position  well  adapted  for  the  examination  of  the  thorax,  and  one  which 
may  be  readily  found  for  a  second  examination.  Of  course  any  other 
determinate  point  than  the  one  described  might  be  chosen.  (See  page  92.) 

I  tested  the  correctness  of  the  plumb-lines  as  a  guide  to  the  position 
of  the  tube,  by  making  two  successive  examinations,  the  patient  getting 
up  and  the  tube  being  moved  after  the  first  examination,  and  both 
patient  and  tube  being  arranged  again  for  the  second.  The  outline  of 
the  heart  and  ribs,  traced  by  means  of  the  fluoroscope  in  these  two  ex- 
aminations, differed  only  by  the  width  of  the  line  marked  on  the  skin. 

Various  other  methods  may  be  used  to  determine  the  proper  position 
for  the  target,  but  it  is  unnecessary  to  detail  them  here. 

hidirect  Plumb-line.  —  When  the  median  line  is  not  available  as  a 
point  of  reference,  an  indirect  plumb-line  (see  Fig.  54)  may  be  used. 
The  method  of  using  this  plumb-line  is  shown  in  Fig.  55. 

Relative  Position  of  Patient,  Tube,  and  Screen  or  Photographic  Plate 
Noted. —  The  comparison  of  two  or  more  X-rays  examinations  made  at 
different  times,  of  a  diseased  organ  or  part,  or  the  comparison  of  a  dis- 
eased with  a  normal  organ  or  part,  is  often  essential ;  therefore  the  rela- 
tive position  of  patient,  tube,  and  screen  or  plate  should  be  noted  at  the 


P^B 


TTOo^ta.^j^c.L  <rf  llui^  k96/^.,  ^Zcth. 


2,^1^-       <^Ic'/7t. 


Fig.  52.  Full  size  of  radiograph  of  pins  inserted  into  cork  at  various  distances  troni  the  vacuum 
tube  and  plate  respectively.  The  figures  in  black  give  the  distance  of  the  plate  from  the  tube ;  those 
in  white,  the  distance  of  the  pins  from  the  plate  (in  inches). 


68       THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

first  examination,  so  that  these  same  positions  may  be  renewed  at  the 
second  or  third  examination. 


Fig.  53.  The  diagrams  are  drawn  to  scale.  In  the  two  left-hand  diagrams  the  target  of  the 
tube  was  75  centimetres  (30  inches)  from  the  plate ;  in  the  two  right-hand  diagrams,  38  centimetres 
(15  inches)  from  the  plate.  The  object  is  6  centimetres  wide  (about  25  inches),  and  the  upper  sur- 
face is  7.5  centimetres  (3  inches)  above  the  plate  or  screen. 

The  shadow  of  the  object  is  indicated  by  a  line  just  above  the  line  representing  the  screen  or  plate. 

These  diagrams  illustrate  the  effect  on  the  shadow  when  the  object  to  be  examined  with  the  fluo- 
rescent screen,  or  photographed,  is  at  some  little  distance  from  the  screen  or  plate ;  when  the  target 
is  at  a  distance  or  near  the  screen  or  plate ;  and,  third,  the  effect  of  the  inclination  of  the  plate  or 
screen  on  the  picture. 


METHODS   OF    EXAMINATION 


69 


It  is  more  comfortable  for  the  patient  and  more  convenient  for  the 
practitioner  to  examine  patients  in  the  hospital  reclining  on  the  stretcher 
on  which  they  have  been  brought  to  the  X-ray  room  from  the  ward. 


Fig.  54.     Indirect  plumb-line.     Scale  ^. 

An  instrument,  which  is  a  form  of  plumb-line,  to  be  used  when  the  patient  is  lying  on  the 
stretcher,  that  I  have  devised  for  determining  the  exact  position  of  the  vacuum  tube  when  it  is 
desired  to  place  it  directly  under  the  point  to  be  examined.  This  instrument  is  especially  useful  in 
cases  where  the  median  line  is  not  available  as  a  point  of  reference.  By  it  the  proper  position  for  the 
tube  may  be  obtained  when  it  is  desired  to  determine  the  right  and  left  borders  of  a  large  heart 
separately. 

This  instrument  is  made  of  strips  of  cedar  3  millimetres  thick  and  2.5  centimetres  wide.  There 
is  a  counterpoise  of  lead  on  the  end  of  the  arm  beyond  A.  The  vertical  piece  from  which  the  arms 
A  and  B  extend  is  made  of  two  strips  of  cedar,  fastened  at  either  end  and  separated  2  centimetres 
in  the  middle  by  a  piece  of  cork.     This  is  done  to  give  stiffness. 

A  piece  of  thin  wood  about  5  centimetres  square,  with  a  depression  in  the  centre  (not  shown  in 
the  figure),  is  placed  on  the  patient  so  that  the  depression  is  over  the  point  to  be  examined,  directly 
under  which  it  is  desired  to  bring  the  vacuum  tube.  The  rounded  point,  .-/,  is  placed  in  the  depres- 
sion, and  the  rest  of  the  instrument  being  free  to  swing,  the  weight,  B,  will  hang  directly  under  A;  the 
position  for  the  target  of  the  tube  is  just  under  B. 


But  out-patients  and  all  those  well  enough  to  walk  to  the  X-ray 
room  may  be  examined,  if  desired,  while  sitting  or  standing ;  though 
even  for  such  patients  the  reclining  position  has  advantages,  not  the 


70        IHK    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

least  being  the  fact  that  the  i)atient  is  in  a  restful  position  and  the  exami- 
nation is  the  reverse  of  irksome  to  him. 


Fu;.  55.     Shows  method  of  using  indirect  plumb-line. 

At  times,  patients  who  have  serious  chest  disease  cannot  lie  down 
without  discomfort,  and  they  should,  of  course,  be  examined  while  sit- 
ting   up.     In    pneumohydro   or  pneumopyothorax    the  sitting    position 


METHODS   OF    EXAMINATION 


71 


should  always  be  used,  and  in  obscure  diseases  of  the  chest  it  is  well  to 
look  at  the  patient  both  when  sitting  up  and  lying  down. 


Fig.  56.     Shows  a  patient  sitting  on  a  high  stool  with  his  back  resting  against  a  vertical 

canvas  support. 

The  fluorescent  screen  is  in  a  shallow  wooden  bo.x  supported  on  the  frame  which  carries  the 
vacuum  tube.  The  tube,  which  has  been  temporarily  removed  from  the  lead-lined  box,  is  71  centi- 
metres (28  inches)  from  the  screen,  directly  and  squarely  behind  the  patient,  and  opposite  the  median 
line  of  the  body.  The  frame  which  carries  the  screen  and  the  tube  can  be  moved  up  or  down  at 
pleasure,  its  weight  being  supported  by  a  counteipoise  inside  the  square  upright  on  the  patient's 
right.     The  vacuum  tube  can  also  be  swung  horizontally. 

When  the  physician  is  seated  in  the  chair,  his  eyes  are  about  on  a  level  with  the  patient's  heart. 
This  method  is  not  as  convenient  as  that  in  which  the  swivel  chair  described  below  is  used.    (Fig.  58.) 

Sitting  Position.  —  For  examining  the  patient  in  a  sitting  instead  of 
a  recumbent  position,  the  following-  arrangements  are  convenient. 

The  patient  is  placed  on  a  stool  as  in  Figs.  56,  57,  or  better  in  a  revolv- 


72       THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

ing  arm-chair,  as  in  Fig.  58,  the  height  of  which  is  adjustable,  similar 
to  what  is  known  as  an  office  chair,  but  provided  with  a  screw  at  one 
side  to  clamp  it  and  prevent  it  from  moving  when  not  desired.  The 
back  is  made  of  leather,  through  which  the  rays  pass  easily,  and  is 
straight,  so  that  the  patient  can  lean  against  it  and  yet  hold  himself  in 
an  upright  position. 


Fig.  57.     Gives  the  rear  view  of  Fig.  56. 


The  position  for  the  feet  of  the  chair,  with  regard  to  the  target, 
should  be  marked  on  the  floor. 

The  tube,  held  in  a  stand  with  a  vertical  adjustment  so  that  it  can  be 
raised  or  lowered,  is  placed  behind  the  patient  at  a  distance  of  75  centi- 


METHODS   OF    EXAMINATION 


Th 


metres  from  the  screen,  on  a  level  with  the  fourth  rib.     The  tube  can 
also  be  swung  horizontally  by  means  of  a  simple  adjustment,  so  that  the 


light  can  pass  through  the  body  at  an  angle,  if  desired,  or  the  tube 
may  be  arranged  as  in   Fig.   58. 


74       THE    ROENTGEN    RAVS    IN    MEDICINE    AND    SURGERY 

The  target  should  be  placed  75  centimetres  from  the  patient  and 
opposite  the  median  line  where  it  is  crossed  by  the  fourth  rib.  To 
obtain  the  proper  distance  from  the  patient,  a  line  of  the  desired  length 
may  be  drawn  on  the  fioor  at  right  angles  to  the  middle  of  the  back  of 
the  chair ;  to  determine  the  proper  height,  the  distance  from  the  floor 
to  the  fourth  rib  may  be  measured  by  a  rod  from  the  floor  up. 

The  physician  should  be  seated  on  a  low  stool  or  chair,  of  such 
a  height  from  the  floor  that  his  eyes  are  at  a  convenient  level  for  look- 
ing at  the  chest  with  the  fluorescent  screen,  the  seat  of  the  patient  being 
higher  than  au  ordinary  chair;  55  centimetres  from  the  floor  is  a  con- 
venient height  for  the  seat  of  the  patient's  chair,  and  35  centimetres 
for  that  of  the  physician's.  The  chair  should  be  turned  all  the  way 
around  during  the  examination  so  that  the  organs  of  the  chest  may  be 
examined  from  all  points  of  view,  the  arms  of  the  patient  being  held 
over  his  head  when  they  interfere  with  the  examination. 

Standing  Position.  — The  patient  can  also  be  examined  while  stand- 
ing if  it  is  desired,  the  tube  being  held  in  the  required  position  by  means 
of  an  adjustable  tube  holder. 

These  cuts  show  the  method  of  examining  the  chest  with  the  target 
of  the  vacuum  tube  placed  at  a  point  opposite  the  junction  of  the 
median  line  of  the  body  with  a  line  drawn  across  the  fourth  ribs  ;  but 
cases  occur  in  which  the  chest  must  also  be  examined  from  other  points 
of  view,  in  order  to  obtain  all  the  information  desired.  Some  of  these 
cases  are  taken  up  in  later  chapters,  but  it  is  unnecessary  to  discuss  them 
all  in  detail,  as  the  principles  upon  which  they  rest  have  been  suffi- 
ciently indicated. 

General  Rules  for  Examin.\tion  with   the    Fluorescent  Screen 

Dark  Room.  —  All  examinations  with  the  fluorescent  screen  or  fluor- 
oscope  should  be  made  in  a  dark  room,  and  light  from  all  sources  should 
be  excluded  ;  even  that  from  the  vacuum  tube  by  enclosing  it  in  a 
box.  Before  making  an  examination  during  the  daytime  the  physician 
must  remain  in  the  dark  room  for  about  10  minutes,  and  if  he  goes  into 
this  room  directly  from  out-of-doors,  he  must  wait  longer  on  light  than 
on  dark  and  cloudy  days.  This  delay  is  irksome  but  necessary,  un- 
less he  adopts  the  simple  expedient  of  wearing  dark  glasses  for  15 
or  20  minutes  before  going  into  the  X-ray  room.  At  one  time  it 
seemed   to   me  that   the  above-mentioned  delay  might  prove  a  serious 


METHODS   OF    EXAMINATION  75 

obstacle  to  making  X-ray  examinations,  but  I  found  that  by  wearing 
dariv  glasses  during  the  last  portion  of  my  hospital  visit,  my  eyes,  on 
going  into  the  dark  room,  were  soon  in  a  condition  for  seeing  the  image 
on  the  fluorescent  screen.  When  a  photograph  is  to  be  taken,  the  dark 
room  and  dark  glasses,  or  the  waiting,  are  of  course  unnecessary. 

Adaptation  of  the  Eyes  to  the  Dark  Room.  —  After  exciting  the  tube, 
if  it  is  uncovered,  the  eyes  see  nothing  in  the  dark  room  except  the 
green  light  in  the  tube  itself  ;  all  else  is  black  darkness  ;  but  after  a  few 
moments  the  eyes  begin  to  recognize  objects  in  the  room,  and  as  soon 
as  this  can  be  done  their  ability  to  see  other  objects  augments  rapidly, 
and  within  a  few  seconds  many  things  are  seen  that  could  not  be  recog- 
nized at  first.  When  the  eyes  are  once  adapted  to  the  darkened  room 
the  power  of  seeing  there  is  not  temporarily  lost  even  if  it  is  left  for 
a  moment  to  go  into  a  lighted  room.  Certain  changes  or  adaptations  to 
conditions  of  light,  which  occur  in  the  eyes,  require  time. 

Eyes  of  different  individuals  do  not  see  equally  well  the  appearances 
on  the  fluorescent  screen.  It  is  not  a  question  of  acuteness  of  vision 
only,  I  think,  but  eyes  differ  in  this  resjiect. 

Examination  with  the  Open  Fluorescent  Screen.  —  The  advantage  of 
this  method  (Fig.  59)  is  that  the  eyes  may  be  at  a  distance  from  the 
screen  when  it  is  necessary  to  study  the  whole  of  a  large  picture,  as  in 
comparing  one  side  of  the  thorax  with  the  other,  —  this  view  is  of  great 
importance  in  diseases  of  the  chest,  —  or  near  to  it,  if  desired,  when 
■some  detail  is  to  be  considered.  The  following  cut  shows  the  method 
of  examination  by  means  of  the  open  screen,  which  is  the  one  I  habitu- 
ally use,  and  for  examinations  of  the  chest  it  is  the  most  satisfactory. 
The  screen  is  30  x  35  centimetres  (12  x  14  inches)  in  size,  and  is  in  a 
shallow  box  open  at  the  top.  A  portion  of  the  plumb-line  at  the  head 
of  the  stretcher  is  seen  in  the  cut,  and  both  ends  of  the  plumb-line, 
that  is  passed  across  the  chest  on  a  level  with  the  fourth  rib,  are  also 
seen.  These  Hnes,  as  already  described,  are  used  to  determine  the 
position  of  the  target.  The  line  across  the  chest  is  usually  removed 
before  the  examination,  but  is  left  in  the  picture  to  show  the  method. 
The  observer  generally  stands  on  the  patient's  right,  but  is  seen  here 
standing  on  his  left  in  order  not  to  obstruct  the  view,  as  the  position  of 
the  static  machine  did  not  permit  the  photograph  to  be  taken  from  the 
left  side. 

When  it  is  desired  to  compare  the  apices  of  the  lungs,  a  screen  with 
a  curved  piece  cut  out  of  one  of  the  sides,  so  as  to  admit  the  chin,  is  use- 


76       THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY  I 

fill,  as  by  this  device  the  screen  can  be  raised  higher  up  on  the  chest, 
and  a  more  complete  view  of  the  apices  can  be  obtained. 


Fig.  59.  1  his  cut  shows  the  method  of  examining  the  whole  thorax  with  a  large  open  screen, 
30  by  35  centimetres,  placed  in  a  shallow  box,  the  side  of  which  is  shown  under  the  hand,  the  dark 
cloth  being  drawn  aside  for  the  purpose.  The  method  here  shown  is  the  best  for  comparing  one  side 
of  the  thorax  with  the  other.  The  observer  is  standing  on  the  left  side  of  the  patient,  in  order  that  the 
latter  may  be  visible.  The  observer  should  stand  on  the  right  side  and  have  one  hand  on  one  of  the 
long  handles  seen  above  the  patient's  head,  as  by  this  means  the  amount  of  light,  which  should  be 
varied  as  the  examination  proceeds,  is  controlled. 


METHODS    OF    EXAiMINATION  ^'j 

The  practitioner  should  be  so  placed,  as  shown  in  Fig.  58,  and 
indicated  in  Fig.  59,  that  he  can  vary  the  amount  of  light  as  the  exami- 
nation proceeds,  without  lifting  his  eyes  from  the  fluorescent  screen ; 
but  the  hght  must  be  adjusted,  as  seems  best,  for  the  actual  moment  of 
drawing.  It  can  and  should  be  altered,  however,  when  needed,  from 
time  to  time,  as  the  different  organs  to  be  traced  demand. 

Examination  from  Different  Points  of  View.  —  It  is  often  an  advan- 
tage to  examine  the  thorax  or  the  extremities  from  different  points  of 
view.  To  this  end  the  patient  may  turn  on  the  stretcher,  or  the  screen 
may  be  moved,  or  both.  More  specific  directions  for  examining  spe- 
cial organs  will  be  given  in  the  chapters  devoted  to  the  consideration 
of  special  diseases. 

Method  for  recording  the  Appearances    seen  on   the    Fluores- 
cent Screen 

The  photograph  makes  a  record  in  itself,  but  the  appearances  seen 
on  the  screen  must  be  made  permanent  for  further  reference.  They  may 
be  recorded  without  removing  the  clothing,  or  with  the  part  to  be  exam- 
ined bared.     The  latter  is  the  better  way  when  the  thorax  is  in  question. 

Without  Removal  of  Clothing  ;  Tracings  made  on  a  Thin  Sheet  of 
Glass  or  Film  of  Celluloid.  —  First,  points  of  reference  are  necessary  in 
order  that  tracings  made  at  different  periods  may  be  compared,  if 
desired  ;  and  these  may  be  obtained  by  placing  pieces  of  metal  over 
certain  parts.  For  instance,  when  examining  the  thorax,  a  piece  of 
metal  rod  covered  with  rubber  is  placed  over  the  sternum  in  the  median 
line,  and  other  pieces  of  metal  over  the  nipples.  The  screen  is  then 
covered  with  a  thin  sheet  of  glass  or  film  of  celluloid  and  placed  on 
the  chest  (see  Fig.  60).  The  shadows  of  the  points  of  reference  are 
first  drawn  in  with  a  lithographer's  pencil,  and  afterward  the  appear- 
ances the  physician  desires  to  record.  The  celluloid  or  glass  may  be 
washed  with  alcohol  and  used  again  after  the  lines  drawn  on  it  have 
been  traced  on  paper. 

With  Removal  of  Clothing  ;  Tracings  made  upon  the  Skin.  —  The 
pencil  used  for  drawing  in  the  outlines  seen  should  make  a  good  mark 
on  the  skin  with  the  slightest  touch,  and  it  should  be  placed  in  a  metal 
holder  or  be  provided  with  a  narrow  strip  of  lead  along  its  length, 
because  this  metal  casts  a  shadow,  and  therefore  the  physician  is  able 
to  follow  its  point  as  he  traces  the  appearances  observed.  I  have  had 
some  special  pencils  made,  but  the  crayons,  in  brass  tubes,  which  actors 


y8       THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY  | 

use  for  pencilling  the  eyebrows  answer  the    purpose  very  well.       No  j 

metal  is  necessary  for  obtaining  the  points  of  reference  as  is  required  j 

in  the  method  just  described.     A  mark  is  made  on  the  skin,  with  the  j 


Fig.  6o.  Shows  method  of  examining  a  patient  with  the  screen  with  celluloid  cover,  on  which 
the  outlines  of  the  heart  and  diaphragm  have  been  traced.  The  diaphragm  under  the  stretcher  is 
pulled  a  little  out  of  place  so  that  it  may  be  better  seen  :  it  should,  of  course,  be  directly  under  the 
outlines,  as  they  are  being  drawn  on  the  screen,  when  an  examination  is  made. 


METHODS   OF    EXAMINATION  79 

radiographic  pencil  described,  over  the  sternal  notch,  and  another  over 
the  ensiform  cartilage,  in  order  to  indicate  the  median  line,  which  has 
been  obtained  by  drawing  a  line  from  the  umbilicus  to  the  sternal  notch. 
The  screen  is  then  held  sufficiently  above  the  surface  of  the  body  to 
allow  the  hand  to  move  freely  while  tracing  upon  the  skin  the  appear- 
ances observed  on  the  screen  (see  Fig.  61).  It  is  well  to  go  over 
all  the  lines  traced  a  second  time  (after  the  patient  has  taken  several 
deep  inspirations),  and  to  check  them  carefully,  in  order  that  no 
mistakes  may  be  made.  The  border  of  an  organ  may  often  be  de- 
termined with  advantage  by  a  series  of  dots,  which  can  be  joined 
after  the  screen  has  been  removed,  instead  of  by  full  lines  ;  for  if  dots 
are  made  there  is  less  likelihood  that  the  skin  will  be  pushed  out  of 
position  by  the  pencil  as  it  moves  over  its  surface,  and  although  it  is 
not  liable  to  be  moved  out  of  place  in  any  case  unless  the  tracing  is 
clumsily  done,  still  these  dots  are  a  simple  precaution.  The  ne.xt  step 
is  to  copy  these  lines  on  to  tracing  cloth. 

Outlines  made  on  the  Skin  traced  on  to  Tracing  Cloth.  —  A  piece  of 
tracing  cloth  or  tracing  paper  about  30  centimetres  square,  across  the 
middle  of  which  a  straight  Hne  has  been  ruled,  is  placed  upon  the  chest  in 
such  a  position  that  its  median  line  falls  directly  over  that  of  the  body. 
The  sternal  notch,  ensiform  cartilage,  and  the  nipples  should  be  traced 
upon  the  cloth,  and,  if  desired,  the  outlines  also  of  any  of  the  ribs  and  the 
costal  border  may  be  added  ;  but  the  former  are  usually  sufficient  as  points 
of  reference.  The  tracings  made  on  the  skin  are  then  retraced  on  to  the 
cloth.  The  cloth  must  be  held  firmly  but  gently  while  these  tracings 
are  made  ;  it  must  not  be  allowed  to  slip  from  its  original  place,  nor 
must  it  be  pressed  so  hard  as  to  slide  it,  and  thus  its  position  or  that  of 
the  skin  be  disturbed.  The  tracings  on  the  chest  should  be  retraced 
on  to  the  cloth  before  the  patient  has  changed  his  position,  and  after 
these  Hues  have  been  copied  the  physician  should  see,  before  removing 
the  cloth,  that  the  tracing  upon  it  agrees  perfectly  with  the  tracing 
ui)()n  the  skin.  The  lines  on  the  skin  are  easily  removed  by  means  of 
a  little  alcohol. 

Measurements  made  on  Chest  transferred  to  Blanks.  —  The  appear- 
ances seen  on  the  chest  may  be  also  recorded  on  suitable  blanks.  Some 
fifteen  or  twenty  years  ago  I  had  a  plate  made  that  gave  the  outlines 
of  the  chest,  which  was  copied  from  an  anatomical  plate,  but  reduced 
so  that  it  was  one-half  the  normal  size.  The  blank  made  from  this 
reduced  plate  I  used  for  making  records  of  auscultation  and  percus- 


8o       THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

sion,  as  any  measurements  made  on  the  chest  could  be  transferred  to 
the  blank  by  reducing  them  one-half.  These  blanks  I  now  also  use  for 
records  of  X-ray  examinations.  The  outlines  drawn  on  the  chest  may 
be  measured,  reduced,  and  transferred  to  the  blanks  as  was  done  with 


Fig.  6i.  Shows  the  method  of  drawing  the  outlines  on  the  patient's  skin  while  looking  through 
the  fluoroscope.  Tlie  fluoroscope  is  held  farther  away  from  the  patient  than  is  necessary  in  practice, 
in  order  that  the  pencil  which  is  under  it  maybe  shown  in  the  picture.  The  observer  usually  stands 
on  the  patient's  right,  but  in  order  to  show  the  method  of  examination  better,  he  is  seen  standing  on 
the  patient's  left. 

The  diaphragm  (see  Fig.  60),  which  is  placed  under  the  patient's  chest  in  order  to  obtain  a 
better  definition  of  the  outlines,  does  not  show  in  this  cut. 


the  records  of  auscultation  and  percussion.  Some  of  the  cuts  given  in 
the  following  pages  to  illustrate  the  appearances  seen  in  the  chest  are 
photographic  reproductions  of  the  records  thus  made  (see  Fig.  io6), 
while  others  are  from  photographs  of  the  tracings  made  on  the  tracing 
cloth  (see  Fig.  82);  both  kinds  of  cuts  are  about  one-third  life  size. 


METHODS   OF    EXAMINATION  8 1 

Additional  Records.  —  The  name  and  age  of  the  patient,  the  vokime 
and  page  of  the  records,  the  diagnosis,  and  any  memoranda  referring 
to  the  X-ray  examination,  should  be  made  upon  the  tracing  cloth  as 
soon  as  it  is  removed  from  the  chest,  or  on  the  blank  described,  in 
order  to  reduce  the  chance  of  any  mistake  to  a  minimum  ;  or  these 
additional  data  (together  with  the  physical  examination,  history,  etc.) 
may  be  made  upon  blanks  of  the  same  size  prepared  for  the  purpose,  and 
pinned  to  the  tracing  cloth  after  the  outlines  have  been  drawn  upon  it. 
A  complete  and  convenient  record  of  a  case  is  thus  obtained  for  filing. 

Methods  of  Localization.  —  Various  methods  have  been  devised  for 
locating  the  position  of  foreign  bodies  and  of  new  growths  in  different 
parts  of  the  body.  Many  of  them  are  very  ingenious,  but  somewhat 
complicated  for  use  by  the  general  practitioner.  The  subject  of  locali- 
zation will  be  further  discussed  in  later  chapters,  but  I  will  outline  four 
simple  methods  that  require  no  special  apparatus  by  which  the  ob- 
server may  determine  whether  the  object  to  be  located  is  nearer  the 
front  or  the  back  of  the  chest.  These  methods  are  based  in  part  on  the 
fact  that  if  the  outline  of  the  shadow  is  sharp  and  not  exaggerated, 
the  object  casting  it  is  near  the  screen. 

The  principle  involved  requires  that  two  examinations  be  made  with 
the  fluorescent  screen,  each  from  a  different  point  of  view  ;  or  two 
X-ray  photographs  may  be  made,  except  when  the  third  method  is 
used.  The  first  method  requires  the  movement  of  the  tube  only,  after 
the  first  examination  has  been  made,  the  position  of  the  screen  remain- 
ing constant  in  the  two  examinations  ;  the  second  method  demands 
that  both  the  screen  and  the  tube  be  moved,  their  respective  positions 
with  regard  to  the  patient  being  reversed  ;  the  third  method  depends 
upon  the  movement  of  the  object  to  be  located  ;  and  the  fourth  upon 
the  movement  of  the  part  of  the  body  in  which  the  given  object  is 
situated.  The  last  method  is  described  in  some  detail  in  the  chapter 
on  Foreign  Bodies,  pages  531  and  532. 

First  Method.  —  The  screen  is  placed  on  the  back  or  front  of  the 
chest,  as  the  case  may  be,  and  the  tube  opposite  the  screen  on  the 
other  side  of  the  patient.  The  position  of  the  shadow  cast  upon 
the  screen  is  then  noted.  Next  the  tube  is  moved  —  vertically  if 
the  patient  is  examined  sitting  up,  and  horizontally  if  he  is  lying  down 
—  through  a  distance  of  30  to  60  centimetres,  and  the  position  of  the 
shadow  is  again  noted.  If  the  object  which  makes  the  shadow  is  near 
the    screen,  there  will  be   little  difference  between  the    two    positions 


82       THE   ROENTGEN   RAYS   IN    MEDICINE   AND   SURGERY 


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O 


0' 


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0  j; 


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METHODS   OF    EXAMINATION 


83 


84       THE    ROENTGEN    RAYS    IN    MEDICINE    AND   SURGERY 

of  the  shadow  and  the  shadows  will  be  more  sharply  defined.  If,  on  the 
contrary,  the  object  is  distant  from  the  screen,  there  will  be  consider- 
able difference  between  the  two  positions  of  the  shadow,  and  the  shad- 


ows will  be  larger  and  less  sharply  defined.  Figures  62  and  63  illustrate 
this  method.  The  screen  is  against  the  back  of  the  chest  and  the  tube 
(not  shown  in  the  cut)  was  placed  in  front  of  the  patient,  60  centimetres 
(2  feet)  distant  from  the  screen,  and  about  as  high  as  the  shoulder  when 


METHODS   OF    EXAMINATION 


85 


the  lower  of  the  two  shadows  was  cast,  and  about  on  a  level  with  the 
umbilicus  when  the  higher  was  cast.  The  object  in  Fig.  62  is  seen  near 
the  back  of  the  chest  and  therefore  the  shadows  are  sharply  defined 
and  near  together.     In  Fig.  63  the  object  is  near  the  front  of  the  chest, 


and  therefore  the  shadows  are  seen  farther  apart,  and  they  are  larger 
and  less  sharply  defined. 

Second  Method.  —  The  screen  is  placed  on  the  back  of  the  patient  and 
the  tube  in  front  of  his  chest,  and  the  definition  of  the  shadow  on  the 


86        THE    ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 

screen  is  noted  ;  the  positions  of  the  tube  and  screen  are  then  reversed 
and  the  definition  of  the  shadow  is  again  noted.  By  comparing  the 
respective  sharpness  of  definition  of  the  two  shadows  it  is  obvious  that 
the  observer  will  be  able  to  determine  whether  the  object  is  nearer  the 
front  or  the  back  of  the  chest,  for  the  nearer  the  object  is  to  the  screen 
the  sharper  is  the  definition  of  the  shadow. 

Third  Method.  — The  object  in  this  case  is  moved  by  the  respiratory 
movement  of  the  lung.  If  it  is  near  the  screen  there  will  not  be  much 
difference  between  the  two  positions  of  the  shadows  cast  in  expiration 
and  inspiration  respectively,  and  the  shadow  will  be  more  sharply 
defined  ;  if  distant  from  the  screen  there  will  be  a  greater  difference, 
the  shadows  will  be  larger  and  less  sharply  defined.  In  order  to  deter- 
mine whether  the  object  is  nearer  the  front  or  the  back  of  the  chest  the 
observer  should  examine  the  patient  with  the  screen  on  the  back  of  the 
patient  and  the  tube  in  front  of  him,  and  next  with  the  relative  positions 
of  the  tube  and  screen  reversed,  and  then  compare  the  distance  which 
the  shadow  moves  and  the  size  of  the  shadows  in  the  two  different 
positions  of  the  tube  and  screen.  Figures  64  and  65  illustrate  this  method. 
See  also  chapter  on  New  Growths,  pages  333  to  338,  case  of  Daniel  M. 

Method  of  Examination  bv  X-Rav  Photographs 

Precautions  necessary  in  taking  Radiographs.  —  Before  a  radiograph 
is  taken  all  metal  should  be  removed  from  about  the  part  as  far  as  pos- 
sible. Buckles  of  metal,  glass  or  bone  buttons,  or  splints  of  metal 
would  interfere  with  the  picture  if  they  came  just  over  the  parts  which 
it  is  desired  to  show  most  clearly.  Wooden  splints  and  dressings  of  cotton 
do  not  interfere  except  in  so  far  as  they  prevent  the  plate  from  being 
brought  close  to  the  bone  of  which  a  radiograph  is  desired.  The  bone  is 
thus  out  of  focus,  as  it  were,  and  its  outlines  are  less  well  defined.  If, 
however,  plaster  is  used,  or  the  dressings  are  thick  and  moist,  or  if  they 
contain  iodoform,  or  any  substance  through  which  the  rays  do  not  pass 
readily,  the  picture  cannot  be  so  satisfactory.  It  is  well  to  remember 
that  a  piece  of  iodoform  may  be  mistaken  for  a  foreign  body,  as  it  is 
quite  as  opaque  to  the  rays  as  some  of  the  metals  (see  chapter  on  Frac- 
tures, Fig.  248).  The  advantage  of  wooden  splints  and  cotton  dressings 
will  be  discussed  in  the  chapter  on  Fractures.  Sticking  plaster  may 
cast  a  shadow  which  would  suggest  a  defect  in  the  bone.  In  medico- 
legal cases,  where  there  is  a  question  of  a  bullet  in  the  body,  no  clothing 


METHODS   OF    EXAMINATION  ^y 

should  be  allowed  to  remain  over  the  suspected  part,  as  a  bullet  might 
be  concealed  in  the  clothing. 

Data  on  Negative.  —  The  distance  of  the  tube  from  the  plate  should 
be  noted  on  the  negative  for  reference,  and  the  point  on  the  skin  directly 
opposite  which  the  target  is  placed  should  be  marked  by  means  of  a 
metal  washer  which  can  be  fastened  in  place  (see  Fig.  263),  if  necessary, 
by  a  small  bit  of  plaster.  Before  the  metal  is  removed  a  minute  quan- 
tity of  staining  fluid  may  be  dropped  into  the  hole  of  the  washer ;  a 
mark  is  thus  left  on  the  skin  which  enables  the  surgeon  to  know  the 
point  of  view  from  which  the  radiograph  was  taken.  These  reference 
points  are  an  aid  to  the  practitioner  in  the  interpretation  of  the  negative 
(see  Chapter  XIX,  page  473,  for  further  remarks  on  this  point),  for  it  is 
important,  in  order  to  understand  the  negative,  to  know  the  direction  and 
distance  of  the  source  of  light ;  with  these  reference  points  the  practi- 
tioner can  put  himself  in  the  same  place  with  regard  to  distance  and  direc- 
tion when  observing  the  negative  as  the  target  occupied  when  the  radio- 
graph was  taken.  As  stated  on  page  65,  the  target  should  be  directly 
opposite  the  object  to  be  examined,  so  far  as  may  be,  but  in  the  case  of  a 
possible  injury  to  the  bone,  for  instance,  this  exact  place  may  not  always 
be  found,  although  this  is  often  possible  if  a  preliminary  survey  is  taken 
by  means  of  the  fluorescent  screen.  The  diagram  shown  on  page  68 
indicates  how  distance  and  direction  would  alter  the  shadow  cast. 

For  further  identification  of  the  position  of  the  negative  with 
regard  to  the  part  photographed,  small  brass  letters  half  a  centi- 
metre high,  that  can  be  bought  at  hardware  stores,  may  be  fastened 
on  to  the  envelope  that  holds  the  plate,  or  to  the  patient's  body,  while 
the  exposure  is  being  made.  For  example,  R  and  L  would  indicate  upon 
which  side  of  an  ex.tremity,  head,  or  trunk  the  plate  was  placed;  A  and  P 
whether  it  was  on  the  anterior  or  posterior  surface.  The  radiograph 
would  show  whether  a  leg  or  arm  had  been  taken,  but  the  word  "  leg  " 
or  "  arm  "  could  be  added  if  desired. 

R.  O.  =  Right  (leg  or  arm)  outer  side. 

/?.  /.    =      "  "  "      inner  side. 

R.  A.  =      "  "  "      anterior  surface. 

R.  P.   =       "  "  "      posterior  surface. 

The  position  of  the  plate  can  be  more  quickly  identified  if  these  letters 
are  always  in  one  part  of  it ;  therefore  it  is  well  in  all  cases  to  place  them 
in  the  upper  right  hand  quadrant,  for  instance. 


88       THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Examination  with  Screen  before  Radiograph  is  Taken.  —  Before  the 
plate  is  put  over  the  part  to  be  photographed,  it  is  often  an  advantage 
to  examine  this  part  with  the  fluoroscope,  in  order  to  learn  the  best  posi- 
tion for  the  plate.  The  plate  is  then  put  gently  over  the  desired  spot 
without  moving  the  patient  or  disturbing  the  part. 

Position  of  Plate.  ^  As  a  rule  the  plate  should  be  placed  above  the 
part  to  be  examined,  and  the  tube  be  put  below  the  patient ;  in  this 
case  the  picture  is  not  reversed  as  regards  right  and  left ;   there  are, 


Fig.  66.     M.  G.     Cut  shows  hyoid  bone  and  part  of  trachea.     Plate  against  side  of  neck. 

however,  some  parts,  as  the  spine,  for  instance,  where  the  radiograph  can 
be  more  conveniently  taken  with  the  position  of  these  objects  reversed. 

If  an  X-ray  photograph  of  the  head  is  to  be  taken,  the  tube  may  be 
placed  either  above  or  below  the  patient,  but  it  is  more  comfortable  for 
the  patient  to  place  it  in  the  latter  positicm  and  to  rest  the  plate  gently 
upon  the  upper  side  of  the  head,  the  plate  being  partly  supported 
by  a  block  under  one  corner  and  steadied  by  a  folded  cloth  placed 
over  it. 

The  plate  should  be  brought  as  near  as  possible  to  the  part  to  be 
photographed;  for  example,  in  taking  a  photograph  of  the  larynx, 
plates  7.5  or   10  centimetres  wide  should  be  used,  in  order  that  they 


METHODS   OF    EXAMINATION  89 

may  be  placed  between  the  lower  jaw  and  the  clavicle,  and   thus  be 
brought  close  against  the  larynx. 

X-ray  photographs  showing  the  hyoid  bone,  the  thyroid  and  cricoid 
cartilages,  may  be  made  by  placing  a  narrow  plate  close  against  the 
side  of  the  neck  (see  Fig.  66). 

It  is  somewhat  better  to  place  the  film  side  of  the  plate  against  the 
patient,  for  two  reasons  :  first,  if  the  other  side  is  next  the  patient,  some 
portion  of  the  rays  do  not  reach  the  film,  as  they  are  absorbed  by  the 
glass  ;  second,  the  film  is  a  little  farther  removed  from  the  part  to  be 
photographed,  and  therefore  the  picture  will  be  less  sharply  defined.  To 
interpret  an  X-ray  picture  as  regards  right  and  left,  it  is  necessary  to 
know  the  relative  positions  of  the  film  side  of  the  plate,  the  patient,  and 
the  tube.  When  the  arrangement  is  as  in  Fig.  69,  fractured  leg,  right 
and  left  are  not  reversed  on  the  print.  The  interpretation  of  the  X-ray 
picture  is  an  important  point,  and  is  further  discussed  in  Chapter  XVII, 
Introduction  to  Surgery,  and  Chapter  XI,  on  Aneurisms. 

The  shoulder  may  be  photographed  with  the  patient  lying  on  his 
back  or  on  his  face  on  the  stretcher.  If  on  his  back,  the  plate  is  placed 
on  the  front  of  the  shoulder,  or  it  may  be  supported  under  the  stretcher, 
as  described  below;  if  on  his  face,  on  the  shoulder  blade. 

If  a  photograph  of  the  knee  is  desired,  the  patient  may  lie  on  his  side 
on  the  stretcher  and  the  plate  be  put  above  the  knee.  A  folded  sheet 
or  cloth  may  then  be  placed  on  the  plate  ;  the  cloth  should  be  large 
enough  to  extend  beyond  the  plate  and  rest  on  the  stretcher,  and 
by  its  weight  steady  the  plate  and  assist  in  keeping  it  in  its  proper 
position. 

The  arch  of  the  foot  usually  shows  best  on  the  plate  when  a 
side  view  of  the  foot  is  taken,  that  is,  with  the  plate  resting  against 
the  inside  of  the  ankle  ;  two  views  may  be  useful  and  are  quite  prac- 
ticable :  one  with  the  patient  standing  and  throwing  the  weight  of 
his  body  on  the  foot ;  and  the  other  sitting.  To  take  a  radiograph  of 
the  foot  with  the  weight  resting  upon  it,  the  patient  should  stand  on  a 
wooden  stool,  the  tube  should  be  placed  on  a  level  with  the  top  of  the 
stool  opposite  the  outside  of  the  foot,  and  the  plate  be  held  against  the 
inside  of  the  foot.  To  make  the  outlines  of  the  bones  on  the  inner  side 
more  easily  distinguished  from  those  on  the  outer  side  of  the  foot, 
the  tube  may  be  placed  only  30  or  40  centimetres  from  the  plate ;  thus 
only  the  bones  near  the  plate  are  sharply  defined  (see  photograph  of 
pins  on  page  67). 


90 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


The  method  for  photographing  different  parts  of  the  body  is  illus- 
trated by  the  following  cuts,  and  will  be  further  discussed  and  illustrated 
in  the  chapter  on  Fractures. 


METHODS   OF    EXAMINATION 


91 


Fractured  Leg.  — The  cut  on  page  92  (Fig.  69)  shows  the  method  of 
photographing  a  fractured  leg.  The  patient  has  been  brought  from 
the  hospital  ward  into  the  X-ray  room  on  a  stretcher  which  was  placed 
on  the  wooden  horses  shown  in  the  picture.  The  stretcher  is  lengthened 
at  the  patient's  head  by  means  of  a  shelf,  hinged  on  to  one  of  the  horses, 
which  may  be  turned  up  when  it  is  desired  to  make  the  stretcher  longer, 
as  in  this  case. 


Fig. 


Another   cut   showing   cervical    vertebrae   and   position   of  some  of  the  parib  in   liuiit  of 
them.     In  the  negative  much  more  detail  can  be  seen  than  in  the  cut. 


The  box  containing  the  X-ray  tube  is  seen  beneath  the  stretcher, 
separated  from  the  patient  by  an  aluminum  screen,  which  is  grounded, 
as  suggested  by  Tesla.  The  target  of  the  vacuum  tube  in  the  case  of  a 
fractured  leg  or  hand,  for  instance,  is  not  placed,  of  course,  under  the 
median  line,  but  directly  under  the  point  to  be  photographed.  The  same 
principle  for  finding  the  proper  position  which  is  described  on  page  66, 
however,  applies  in  this  case.    A  line  with  weights  on  either  end  is  thrown 


92 


THE    ROENTGEN    RAYS    IN    MEDICINE    AND   SURGERY 


over  the  body  and  across  the  part  to  be  photographed,  forming  two  phimb- 
lines,  a  line  joining  which  would  be  at  right  angles  to  the  length  of  the 


stretcher.      Next,  the  distance  between  the  metal  washer  (see  page  8/) 
and  the  plumb-line    near   it  against  the  stretcher  is  measured,  and  is 


METHODS    OF    EXAMINATION  93 

found  to  be  x  centimetres.  The  physician  then  sights  from  plumb- 
Hne  to  plumb-line  to  obtain  the  line  on  which  the  tube  should  be  placed, 
and  finds  the  exact  point  on  this  line  for  the  target  by  measuring  off  on 
it  X  centimetres,  using  the  end  of  the  plumb-line  hanging  over  the  side 
of  the  stretcher,  near  the  metal  washer,  as  a  starting-point.  The  target 
is  thus  brought  directly  under  the  metal  washer. 

The  curtain  seen  in  the  background  of  the  picture  hangs  in  front  of 
the  machine  in  order  that  the  apparatus  may  not  excite  the  apprehen- 
sions of  the  patient.  There  is  no  noise  to  disturb  the  patient,  as  the 
static  machine  is  noiseless  unless  the  spark-gap  is  used,  and  if  the  tube 
is  such  that  the  use  of  the  spark-gap  is  not  required,  the  heart  sounds 
can  be  listened  to  and  heard  while  the  apparatus  is  in  motion.  (See 
Chapter  II,  page  17.)  The  handle  hanging  in  front  of  the  curtain  on 
the  left  is  used  to  open  or  close  the  circuit ;  the  other  two  control 
the  spark-gap,  and  by  them  the  amount  of  light  in  the  tube  may  be 
varied.  The  speed  controller,  another  means  of  controlling  the  amount 
of  energy  going  through  the  tube,  is  within  convenient  reach,  but  is  not 
shown  in  the  picture  ;  it  regulates  the  revolutions  of  the  electric  motor 
used  to  drive  the  static  machine,  and  by  varying  the  speed  of  the  plates 
the  amount  of  electricity  adapted  to  various  needs  may  be  obtained,  as 
stated  in  Chapter  II. 

If  the  hand  and  forearm  are  to  be  photographed,  the  given  part  may 
rest  upon  a  table  while  the  patient  sits  in  a  comfortable  chair,  but  these 
and  all  other  parts  of  the  body  are  conveniently  photographed  with  the 
patient  lying  on  the  stretcher.  The  position  is  a  comfortable  one,  and 
enables  the  patient  to  keep  the  given  part  at  rest. 

Fractured  Hand.  —The  following  cut  (Fig.  70)  is  likewise  illustrative 
of  the  method  for  photographing  the  leg,  knee,  or  shoulder. 

Ringel  ^  found  that  he  obtained  a  better  photograph  of  the  hand  if 
it  were  compressed  with  a  rubber  bandage  and  all  the  blood  driven  out, 
than  if  it  were  taken  in  its  natural  condition. 

Method  for  photographing  Heart  or  Lungs.  —  The  cut  (Fig.  71,  given 
on  p.  95)  shows  the  method  for  taking  a  photograph  of  the  heart 
or  lungs,  or  any  organ  or  growth  lying  nearer  the  front  than  the  back  of 
the  chest.  The  patient  is  seen  lying  on  the  stretcher  with  the  photo- 
graphic plate  on  the  front  of  his  chest  and  pressed  squarely  against  it 
by  a  weight  placed  on  a  cross-piece  of  wood.     The  ends  of  the  cross- 

^  "Zur  Diagnose  der  Nephrolithiasis  durch  Roentgenbilder,"  Arch.  f.  klin.  Chir.,  Berlin, 
1899,  lix,  167-174. 


94       THE    ROENTGEN    RAYS    IN    MEDICINE    AND   SURGERY 

piece  are  supported  on  blocks  which  are  set  on  strips  of  thin  pine  board 
that  lie  on  the  horses,  one  on  each  side  of  the  stretcher. 


Method  for  photographing  Spine.  —  It  is  uncomfortable  for  the  patient 
to  lie  on  a  hard  glass  plate,  and  pressure  or  the  moisture  of  perspira- 


METHODS   OF    EXAMINATION 


95 


tion  may  injure  its  surface  ;  there  is  also  the  risk  of  breaking  it  to  be 
considered,  even  when  it  is  supported  on  a  board  ;  but  the  comfort  of 
the  patient  and  the  safety  of  the  plate  may  be  secured  when  the  spine, 


for  instance,  is  to  be  photographed,  by  simply  supporting  the  plate  on 
the  diaphragm,  as  shown  in  Fig.  72.  In  this  way  the  plate  is  brought 
into  close  contact  with  the  spine,  the  patient  is  comfortably  supported 


96       THE    ROENTGEN    RAYS   IN    MEDICINE    AND   SURGERY 

by  the  canvas  stretcher,  and  yet  no  moisture  from  or  weight  of  the 
patient  comes  upon  the  plate. 

X-Ray  Negatives  compared  with  X-Ray  Photographs.  —  X-ray  nega- 
tives show  more  detail  than  the  prints  made  from  them ;  and,  further, 
the  negatives  themselves  may  show  some  things  in  the  process  of  devel- 
opment which  are  lost  in  the  finished  negative.  Negatives  when  dry 
are  denser  and  better  than  when  wet. 

Careful  Examination  of  Negative.  —  A  negative  should  be  examined 
carefully  and  systematically  by  a  suitable  and  variable  illumination  in 
order  to  see  best  what  it  shows.  Sometimes  certain  things  are  seen  most 
clearly  when  the  negative  is  held  above  a  large  sheet  of  white  paper 
which  reflects  the  light  from  a  window ;  often  certain  points  are 
observed  which  we  should  otherwise  overlook  when  the  light  comes 
through  the  negative  at  a  very  acute  angle  rather  than  at  right  angles. 
The  negative  should  be  so  held  that  the  light  goes  through  it  without 
coming  directly  into  the  eyes  of  the  observer,  and  moved  about  so  that 
it  may  be  examined  from  different  points  of  view.  The  following  way 
is  an  excellent  one  for  studying  the  negative  (see  Fig.  y^). 

Thin  negatives  require  but  little  illumination,  dense  ones  more, 
and  very  dense  ones  need  direct  sunlight  in  order  that  details  may  be 
revealed. 

Two  or  More  Negatives  Made.  —  Under  certain  conditions  two  or  more 
negatives  should  be  made.  This  point  will  be  discussed  in  more  detail 
in  Chapter  XVII. 

Intensifying  Screens.  —  Screens  of  tungstate  of  calcium,  if  put  next 
the  photographic  plate,  diminish  greatly  the  time  of  exposure,  but  they 
likewise  lessen  the  clearness  of  the  picture.  I  used  screens  of  this  kind 
some  five  years  ago,  but  discarded  them  because  the  quality  of  the  pic- 
ture was  not  as  good  with  as  without  them.     (See  Appendix.) 

Length  of  Exposure.  —  The  length  of  exposure  necessarily  varies  wuth 
each  form  of  machine,  the  part  to  be  taken,  and  the  tube  used  ;  these 
points  must  be  determined  by  a  few  trials  with  each  apparatus.  If  the 
details  of  the  bones  are  required,  a  longer  exposure  may  be  given  than 
when  a  photograph  of  the  soft  parts,  such  as  the  ligaments  and  muscle, 
is  desired.  The  proper  length  of  exposure  may  often  be  estimated  by 
examining  the  part  with  the  fluoroscope  held  a  few  centimetres  above 
the  plate  and  noting  the  amount  of  light  coming  through.  After  some 
experience  the  correct  exposure  for  a  given  part  may  be  well  determined 
in  this  way. 


Fig.  72.  Sh.jws  the  iihdtdgriipliiL'  piat'',  supijorted  h_\- what  is  urdin.inl\  u;l  .  a;  .i  , .:.!,,■. .;jgni, 
which  is  pressed  up  against  the  patient's  back.  The  tube  with  the  aluminum  screen  below  it  is  seen 
above  the  patient.  The  clothes  should  be  removed  when  taking  such  a  picture,  and  a  blanket  thrown 
over  the  patient,  as  the  shadows  cast  by  the  buttons,  for  example,  might  be  misleading. 


98 


THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


In  taking  photographs  of  parts  of  unequal  thickness,  for  instance 
the  fingers  and  wrist,  it  is  impossible  to  get  the  proper  exposure  for  all 
parts  unless  the  thinner  parts  are  protected  during  a  portion  of  the  time 
of  exposure.  This  may  be  done  by  passing  a  plate  of  lead  to  and  fro 
between  the  fingers  and  the  tube,  and  making  the  exposure  long  enough 
to  give  a  satisfactory  picture  of  the  wrist.     In  a  hand  which  I  made  in 


Fig.  73.  Shows  a  simple  way  of  examining  a  negative  by  a  suitable  and  variable  illumination. 
The  negative  is  placed  in  a  frame  which  is  hinged  at  the  bottom  to  a  stand,  as  shown  in  the 
picture.  The  lower  half  of  this  frame  contains  a  piece  of  ground  glass,  upon  which  the  negative  is 
laid;  the  upper  half  forms  a  shade  for  the  negative;  this  shade  may  be  made  more  effective,  if 
desired,  by  fastening  a  piece  of  dark  cloth  (not  sh«wn  in  the  cut)  on  either  side  of  it.  Behind  and 
below  the  negative  is  another  frame,  which  can  be  tilted.  This  frame  carries  a  mirror,  or,  if  preferred, 
a  dull  white  surface  can  be  used.  The  angle  of  the  mirror  should  be  varied  while  the  negative  is 
studied,  in  order  to  obtain  .the- most  suitable  light  for  the  special  portion  observed.  This  stand  is 
placed  on  a  table  near  a  window,  and  the  observer  sits  in  front  of  it  to  study  the  negative,  as  shown  in 
the  cut. 

1896,  this  method  was  resorted  to,  the  result  being  a  good  picture  of  the 
wrist,  also  showing  clearly  the  details  of  the  fingers  and  the  finger  nails. 
Importance  of  taking  Two  Pictures  each  from  a  Different  Point  of 
View  when  making  an  Examination.  —  It  is  often  necessary  to  take  two 
views  of  a  fracture,  a  new  growth,  or  a  foreign  body  ;  for  instance,  one 
from  a  lateral,  and  the  other  from  an  antero-posterior  point  of  view. 
This  subject  will  be  further  dwelt  upon  in  the  chapters  on  Surgery. 


METHODS   OF    EXAMINATION 


99 


Comparative  Advantages  of  Screen  and  X-Ray  Photographs.  —  It  is 

more  convenient  to  use  the  fluorescent  screen  in  many  cases  than  to  take 
an  X-ray  photograph.  With  the  screen  the  results  of  the  examination 
may  be  obtained  directly  ;  and  when  the  organs  are  movable,  as  the 
lungs  or  heart,  the  amount  of  this  movement  and  the  changes  taking 
place  under  different  respiratory  conditions  may  be  studied,  a  point  of 
the  utmost  importance.  Therefore,  for  studying  the  conditions  of  the 
thorax  it  is  generally  an  advantage  to  use  the  screen  rather  than  the 
X-ray  photograph.  Likewise,  in  locating  foreign  bodies,  the  screen  is 
sometimes  better  than  the  X-ray  photograph  ;  also  the  screen  affords  a 
convenient  means  for  making  a  preliminary  examination  to  secure  the 
most  advantageous  points  of  view  for  taking  radiographs.  On  the 
other  hand,  the  radiograph  gives  more  detail,  and  by  its  means  much 
may  be  recognized  which  would  wholly  escape  observation  if  the  screen 
alone  were  used.  For  instance,  a  case  of  fracture,  where  there  is  no 
displacement,  would  be  overlooked  with  the  screen  and  seen  in  the 
radiograph.  Both  methods  of  examination  should  be  used  in  some 
cases. 

Speaking  generally,  the  X-ray  examination  by  the  photograph  is 
better,  as  a  rule,  than  that  by  the  fluorescent  screen  for  all  parts  of  the 
body  except  the  trunk,  but  more  especially  except  the  thorax.  I  may 
say  that  the  photograph  is  more  suitable  for  the  surgeon,  and  the 
fluorescent  screen  for  the  physician.  The  relative  usefulness  of  the 
screen  and  photograph  will  be  further  discussed  in  succeeding  chapters. 

In  making  examinations  with  this  new  method,  as  with  the  older 
ones,  the  three  following  stages  should  be  kept  distinctly  and  separately 
in  mind  :  — 

First :  Attention  should  be  given  to  observing  carefully  the  appear- 
ances which  present  themselves. 

Second  :  A  careful  record  should  be  made  of  these  appearances  in 
some  simple  and  direct  way  which  shall  be  a  record  of  facts,  not  of 
opinions. 

Third  :  The  observations  made  should  be  well  considered  by  them- 
selves and  in  connection  with  information  furnished  from  other  sources, 
the  evidence  from  each  source  being  given  just,  but  not  exclusive,  con- 
sideration before  making;  the  diagnosis. 


CHAPTER    IV 

INTRODUCTION    TO    THORAX 

To  use  the  Roentgen  rays  successfully  in  practice,  the  physician 
must  first  become  familiar  with  the  appearances  on  the  screen  or  photo- 
graph, or  both,  which  present  themselves  in  health  ;  this  statement 
applies  particularly  to  the  thorax,  and  the  picture  of  this  part  of  the 
body  when  seen  on  a  large  fluorescent  screen  presents  so  much  that 
it  should  be  studied  systematically. 

General  View.  —  The  trunk  is  lighter  above  than  below  the  dia- 
phragm, and  the  rise  and  fall  of  this  muscle,  which  appears  dark  on  the 
screen,  is  distinctly  seen.  The  chest  is  divided  vertically  by  an  ill- 
defined  dark  band,  which  includes  the  backbone,  on  each  side  of  which 
the  lungs,  forming  the  brightest  part  of  the  picture,  are  crossed  by  the 
darker  ribs.  The  pulsating  heart  is  seen,  especially  the  dark  ventricles, 
and,  under  favorable  conditions,  the  lighter  right  auricle,  and  on  the 
left  side  above  the  ventricles  the  pulmonary  artery  is  made  out.  A 
small  portion  of  one  side  of  the  arch  of  the  aorta  mav  be  observed  in 
the  first  intercostal  space  to  the  left  of  the  sternum.  After  this  general 
view  has  been  taken,  the  special  parts  should  be  examined  separately. 
Let  us  begin  with  the  lungs. 

Normal  Lungs.  —  These  organs  appear  bright  on  the  fluorescent 
screen,  but  there  is  a  difference  in  the  degree  of  their  brightness  at  dif- 
ferent periods  of  respiration.  In  full  inspiration  they  are  brighter  than 
during  expiration,  as  shown  by  the  following  experiment  which  I  made 
in  1896:  When  a  pasteboard  box  containing  water  2.5  centimetres 
deep  was  held  over  the  chest  of  a  large  healthy  man,  I  could  see  its 
shadow  during  full  inspiration,  but  not  in  expiration.  That  is  to  say. 
in  the  latter  case  there  was  not  sufficient  difference  in  the  amount  of 
light  coming  through  the  lungs,  and  the  lungs  and  the  water,  during 
expiration,  for  a  difference  in  the  shadow  to  be  observed. 

Another  experiment  which  I  made  at  the  same  time  shows  how 
readily  the  substance  of  the  lung  is  traversed  by  the  X-rays.     I  com- 


INTRODUCTION    TO   THORAX 


lOI 


pared  a  normal  lung,  taken  from  a  post-mortem  examination,  and  blown 
up  to  about  the  distension  of  full  inspiration,  with  a  measured  depth  of 
water,  and  I  found  that  the  shadow  cast  by  this  lung  where  it  was  7.2 


Fig.  74.  Diagram  of  full  inspiration  during  health. 
The  broken  lines  show  the  position  of  the  diaphragm  and  heart  in  expiration,  but  the  diagram 
does  not  indicate  that  during  this  time  the  light  area  is  narrower.  The  level  of  the  nipples  is  indicated 
by  the  dark  lines  at  the  sides  of  the  cut  and  near  the  axillae.  The  target  of  the  vacuum  tube  would  be 
placed  under  the  median  line,  where  it  is  crossed  by  a  line  joining  the  nipples,  to  obtain  such  a 
picture. 

centimetres  thick  corresponded  to  that  thrown  by  water  only  6  milli- 
metres deep. 

In  thin  persons  the  lungs  appear  lighter  than  in  stout,  because  in  the 
latter  there  is  a  thicker  layer  of   tissues  between  the  screen  and  the 


I02     THE   ROENTGEN    RAVS   IN    MEDICINE   AND   SURGERY 

tube  ;  therefore,  in  determining  whether  or  not  the  puhiionary  area  is 
of  normal  brightness  in  a  given  individual,  we  must  take  into  account 
the  thickness  of  the  chest  walls ;  in  persons  of  average  size  and  build 
these  walls  would  offer  about  as  much  obstruction  to  the  rays  as  water 


Qer/rac/e  3 
JVormaf 


Fin.  75.    Gertrude  S.,  25  years  old.    X-ray  outlines  of  normal  chest.     (One-third  life  size.) 

These  outlines,  including  those  of  the  ribs  and  clavicles,  are  reduced  photographically  from  the 
tracing  made  of  the  outlines  drawn  on  the  front  of  the  patient's  thorax.  The  full  lines,  with 
the  exception  of  the  outlmes  of  the  bones,  indicate  the  position  of  the  parts  in  deep  inspiration ; 
the  broken  lines  in  expiration;  the  dotted  line  shows  about  the  limit  of  the  bright  pulmonary  area. 

The  ribs  on  the  back  are  not  shown,  as  they  would  confuse  the  picture. 

The  target  of  the  vacuum  tube  was  placed  under  the  point  where  the  line  joining  the  nipples 
was  crossed  by  the  median  line. 


from  5  to  7.]  centimetres  deep.  It  has  seemed  to  me  that  the  right 
ape.x  was  normally  darker  than  the  left  apex  (I  have  not  yet  compared 
the  chests  of  left-handed  persons  with  right-handed  persons  of  the  same 
build).     The  normal  brightness  of  the  lungs  during  full  inspiration  and 


INTRODUCTION    TO   THORAX  103 

expiration  should  be  observed,  for  as  we  note  different  degrees  of  pallor 
by  reference  to  our  standard  of  color  in  health,  in  the  same  way  it  is 
necessary  to  know  the  normal  amount  of  hght  that  should  penetrate 
any  given  part  in  order  to  recognize  any  variations  from  the  normal. 
The  eye  must  be  trained  in  the  use  of  the  X-rays,  as  is  the  ear  for 
auscultation  and  percussion.  Moreover,  as  in  percussion,  and  to  some 
extent  in  auscultation  of  the  lungs,  we  recognize  differences  in  different 
individuals,  which  may  be  within  normal  limits,  and  learn  to  know 
what  note  to  expect  from  a  thorax  of  a  given  size  and  build,  so  must  we 
learn  by  experience  to  recognize  normal  differences,  dependent  on  these 
same  conditions,  in  the  appearances  seen  on  the  fluorescent  screen. 

Experiments  with  Abnormal  Lungs.  — Experiments  that  I  have  made 
with  tuberculous  and  pneumonic  lungs  taken  from  autopsies  showed 
that  the  abnormal  portions  cast  a  dark  shadow  on  the  screen.  (See 
chapter  on  Pneumonia,  page  165,  and  chapter  on  Tuberculosis, 
page  112.)  Another  lung,  from  an  autopsy  that  I  examined,  was 
normal,  except  for  a  small  red  nodule  less  than  i  centimetre  in  diam- 
eter ;  this  nodule  was  seen  on  the  fluorescent  screen  as  a  dark  spot 
on  a  bright  ground,  even  this  small  area  casting  a  well-defined  and 
conspicuous  shadow. 

Clavicles  and  Ribs.  —  The  normal  outlines  of  the  clavicles  and  ribs 
should  also  be  noted  ;  the  observer  should  see  not  only  the  outline  of 
the  ribs  on  the  front  of  the  chest,  but  also  those  at  the  back  during  full 
inspiration  (see  Fig.  ^6).  If  they  are  not  seen,  either  the  chest  offers 
more  obstacle  to  the  rays  than  obtains  under  normal  conditions,  the 
lungs  are  somewhat  congested,  or  the  apparatus  is  not  working  satis- 
factorily, or  the  eyes  of  the  observer  are  not  in  good  condition  for 
seeing. 

Standards  of  Measurement.  —  The  readiest  way  of  deciding  whether 
the  tube  and  the  eyes  are  or  are  not  at  fault  is  to  examine  the  bones  of 
the  hand  with  the  screen,  and  determine  at  how  great  a  distance  they 
can  be  differentiated  from  the  flesh  as  compared  with  what  has  been 
observed  on  former  occasions  when  the  tube  and  the  eyes  were  known 
to  be  fit  for  use  ;  in  doubtful  cases,  where  these  possibilities  of  error 
have  been  ehminated,  the  appearances  seen  on  the  fluorescent  screen 
may  be  compared  with  those  observed  when  a  normal  individual  was 
examined. 

The  instrument  described  below  may  also  be  used  as  a  standard 
of  comparison. 


I04     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 


INTRODUCTION    TO   THORAX 


105 


Densitometer.  —  I  designed  this  instrument,  to  which  I  have  given 
the  name  of  densitometer,  in  order  to  measure  the  density  of  any 
part  of  the  thorax,  and  I  chose  water  as  a  means  of  measurement, 
because  this'  hquid  is  most  akin  to  the  soft  tissues  of  the  body,  they 
being  chiefly  made  up  of  it,  as  well  as  to  the  pathological  deposits  in 
the  lungs. 

The  instrument  consists  of  an  oval  box  with  two  bottoms,  and  is 
divided  into  halves,  A  and  B,  by  a  partition  that  reaches  nearly  to  the 


Fig.  77.     Densitometer.     Instrument  lor  measuring  density  ot  thorax.     Section  and  plan. 


false  bottom.  The  sides  of  this  box  and  the  partition  are  made  of 
copper,  the  top  and  both  bottoms  of  thin  sheets  of  aluminum.  The 
half  A  is  closed  above,  and  is  supphed  with  a  stopcock  and  a  rubber 
tube ;  the  half  B  is  covered  with  a  lid.  Between  the  two  bottoms  are 
placed  pieces  of  two  or  three  ribs,  or  pieces  of  ivory,  corresponding  in 
density  to  the  ribs,  may  be  used.  There  are  grooves  on  the  inside  of 
the  half  B  which  are  i  centimetre  apart  (see  Fig.  77).  The  section  of 
the  box  is  shown  at  the  right  of  the  cut. 


I06     THE    ROENTGEN    RATS   IN    MEDICINE   AND   SURGERY 

Directions  for  its  Use.  —  The  stopcock  in  the  half  A  is  closed;  the 
Hd  of  the  half  B  is  opened,  and  water  poured  in  until  it  is  nearly  filled  ; 
the  stopcock  in  A  is  then  opened,  and  the  water  flows  under  the  parti- 
tion and  rises  into  this  half.  When  the  instrument  is  thus  prepared,  it 
is  placed  close  beside  the  patient's  chest,  and  between  it  and  the  arm, 
and  while  the  chest  is  examined  with  the  fluorescent  screen,  the  level 
of  the  water  in  B  is  changed  as  desired  by  blowing  air  into  A  or  suck- 
ing air  out  of  A.  When  the  shadows  of  the  ribs  in  the  body  and  in 
the  densitometer  are  equally  dark,  and  the  light  on  the  portion  of  the 
fluorescent  screen  over  B  corresponds  to  the  light  on  the  portion  of 
the  screen  over  the  thorax,  the  stopcock  is  closed,  the  lid  is  opened,  and 
the  depth  of  water  is  read  off  in  centimetres. 

The  density  of  the  lungs  or  any  part  of  the  thorax  in  a  given  patient 
may  be  thus  measured,  and  any  changes  obtaining  at  a  subsequent 
examination  may  be  noted.  The  instrument  can  also  be  used  to  make 
a  scale  with  which  to  determine  the  respective  density  of  the  thorax  and 
other  parts.  It  likewise  enables  us  to  know  whether  the  shadow  seen 
on  the  screen  when  examining  a  patient  is  due  to  the  fact  that  the 
eyes  of  the  observer  are  not  in  a  suitable  condition  for  seeing,  or  that 
the  tube  is  not  giving  a  proper  amount  of  light,  or  that  the  chest  or  any 
given  part  of  it  is  offering  more  obstruction  to  the  passage  of  the  rays 
than  normal. 

A  good  standard  of  measurement  in  diseases  of  the  lungs,  and  one 
that  answers  in  most  cases,  is  the  comparison  of  one  side  of  the  chest 
with  the  other.     (See  chapter  on  Tuberculosis,  page  119.) 

Diaphragm  Lines.  —  The  curve  of  the  diaphragm  and  the  excursion 
made  by  this  muscle  during  quiet  breathing,  and  during  full  inspiration 
and  forced  expiration,  should  be  noted.  Figure  78  shows  the  diaphragm 
lines  in  quiet  breathing  and  deep  inspiration,  which  I  drew  in  1896:  ^  — 

Average  Normal  Excursion  of  Diaphragm.  —  In  twenty-eight  men 
recently  examined,  between  twenty  and  thirty  years  of  age,  who  were 
not  suffering  from  any  disease,  I  found  the  average  excursion  between 
expiration  and  full  inspiration  to  be  6.8  centimetres  on  the  right  side, 
and  7.1  centimetres  on  the  left  side.  In  eighteen  of  these  the  dia- 
phragm moved  during  quiet  breathing  1.7  centimetres  on  the  right  side, 
and    1.5   centimetres   on   the  left.     In   fifteen  of  these  the  diaphragm, 

1  Cuts  showing  the  diaphragm  lines  are  also  given  in  an  article  which  I  published  October  i, 
1896,  "  A  Method  for  more  fully  determining  the  Outline  of  the  Heart  by  means  of  the  Fluoro- 
scope,  together  with  Other  Uses  of  this  Instrument  in  Medicine." 


INTRODUCTION   TO   THORAX 


107 


Fig.  78.     Chest  of  man,  showing  diaphragm  lines  in  quiet  breathing  and  deep  inspiration,  and 
part  of  the  outUne  of  the  heart.     (From  Med.  and  Surg.  Report,  Boston  City  Hospital,  January,  1897.) 


^zr 


Fig.  79.  Tracing  from  normal  chest  of  a  man  twenty-eight  years  old.  Diaphragm  lines;  the 
lowest  full  curved  lines  are  the  diaphragm  lines  in  deep  inspiration  ;  the  two  broken  lines  parallel  to 
these,  the  lines  in  the  inspiration  and  expiration  of  quiet  breathing,  respectively;  the  dotted  lines 
above  these,  the  diaphragm  lines  in  forced  expiration.     (One-third  life  size.) 


Io8     THE    ROENTGEN    RAVS   IN    MEDICINE   AND   SURGERY 

during  forced  expiration,  was  raised  2  centimetres  higher  than  the  point 
reached  in  ordinary  expiration  on  the  right  side,  and  2.3  centimetres 
on  the  left. 

In  forty-five  normal  adults,  thirty-one  men  and  fourteen  women,  of 
various  ages,  the  average  excursion  of  the  diaphragm  was  somewhat 
greater  in  the  younger  adults  than  in  the  older. 

I  have  made  a  number  of  other  measurements  of  the  movement  of 
the  diaphragm,  but  the  cases  in  which  this  has  been  done  are  not  suf- 
ficiently numerous  to  give  the  results  here. 

In  quiet  breathing  the  average  excursion  is  about  i|  centimetres 
when  both  lungs  are  normal,  but  if  one  lung  has  to  do  more  than  its 
share  of  the  work,  the  diaphragm  on  the  well  side  has  a  greater  excur- 
sion than  normal. 

The  normal  excursion  of  the  diaphragm  varies  with  the  dimensions 
of  the  chest.  In  tall  persons  with  a  long  thorax  the  excursion  is  longer 
than  in  short  persons  with  a  very  deep  chest ;  therefore  it  might  be  short 
on  both  sides  in  a  patient  who  is  perfectly  well.  This  point  must  be 
borne  in  mind,  for  otherwise  the  practitioner  may  think  an  abnormal 
condition  exists  where  none  is  present. 

Heart.  —  The  appearances  seen  on  the  screen  when  the  heart  is 
normal,  as  well  as  when  it  is  abnormal,  are  discussed  in  the  chapter  on 
the  Heart,  and  therefore  need  not  be  dwelt  upon  here. 

Blood-vessels.  —  The  position  of  the  large  pulmonary  vessels,  the 
arch  of  the  aorta  and  the  venae  cavae,  should  be  noted  so  far  as  possible. 

Relative  Usefulness  of  Screen  and  Radiograph  in  Examinations  of  the 
Thorax. — The  screen  gives  the  observer  the  opportunity  of  watching 
the  moving  organs,  as  indicated  in  Chapter  III,  to  note  and  measure  the 
excursion  of  the  diaphragm  in  inspiration  and  expiration,  and  the  move- 
ment of  the  heart  and  its  amount,  during  the  different  stages  of  respi- 
ration ;  and  these  observations  can  be  quickly  made.  A  photograph 
cannot  give  as  sharp  outlines  of  moving  organs  as  the  screen,  unless  it 
is  an  instantaneous  picture  ;  often  two  or  more  would  be  necessary,  and 
even  then  would  not  give  as  much  information,  and  in  the  nature  of 
things  there  must  be  some  delay  in  developing  the  negative. 

Further,  it  is  difficult  to  judge  of  the  proper  time  of  exposure  in 
making  a  photograph  of  the  lungs,  for  instance  ;  too  short  or  too  long 
an  exposure  may  interfere  with  success;  again,  prints  made  from  the 
same  negative  may  vary.  I  have  tried  to  overcome  this  possible 
source  of  error  by  taking   two   or   more  prints  from  a  given  negative 


INTRODUCTION    TO   THORAX 


109 


and  comparing  them.  Likewise  the  photograph  made  from  a  plate 
placed  on  the  front  of  the  chest  of  a  given  patient  may  show  a  smaller 
amount  of  diseased  area  than  when  the  plate  is  placed  on  the  back.  To 
overcome  this  disadvantage  two  photographs  should  be  taken,  the  pa- 
tient lying  on  his  back  in  both  cases  unless  he  is  suffering  from  pneu- 
mohydrothorax.  Again,  the  X-ray  photograph  does  not  always  show 
any  definitely  recognizable  difference  between  the  clearness  of  the  out- 
lines of  the  clavicle  and  the  ribs  near  the  apex  of  the  diseased  lung, 
and  those  on  the  unaffected  side  during  deep  inspiration,  nor  between 
the  density  of  the  two  lungs ;  and  yet  this  difference  would  be  easily 
seen  on  the  fluorescent  screen. 

Moreover,  it  is  very  desirable  when  examining  the  chest  to  use  all 
the  methods — inspection,  percussion,  auscultation,  and  X-ray  examina- 
tion —  at  the  same  visit,  as  these  different  methods  support  and  assist 
each  other,  and  to  base  the  diagnosis  on  the  result  of  this  collective  ex- 
amination. 

Again,  if  it  is  a  question  of  determining  the  position  of  a  new 
growth,  for  example,  in  the  thorax,  it  is  very  desirable  to  turn  the 
patient  and  examine  him  with  the  light  going  through  the  chest  in 
various  directions,  and  the  screen  enables  the  observer  to  do  this  with 
ease  and  quickness  (this  point  will  be  illustrated  in  the  chapter  on  New 
Growths  and  elsewhere);  if  the  photographic  method  were  used,  two  or 
more  pictures  would  be  necessary.  The  screen  also  shows  readily 
whether  or  not  the  new  growth  moves  during  deglutition  or  respira- 
tion, and  the  photograph  could  not  easily  demonstrate  this  point. 

It  has  been  argued  as  a  disadvantage  of  the  screen  that  it  does  not 
afford  a  mechanical  record  of  the  results  obtained,  as  does  the  X-ray 
photograph  and  the  thermometer.  The  same  is  true  of  other  methods 
of  examination  successfully  carried  out,  for  example,  those  made  by 
auscultation  and  percussion  ;  but  we  could  not  afford  to  do  without 
these,  nor  can  we  dispense  with  the  screen,  as  the  following  pages 
will  show. 

For  examination  of  the  chest  I  am  satisfied  that  the  screen  gives 
fuller  evidence  and  is  altogether  more  serviceable.  The  question  of  the 
comparative  usefulness  of  screen  and  photograph  in  diseases  of  the 
thorax  will  be  taken  up  again  in  succeeding  chapters. 

Reproductions  of  X-ray  photographs  of  the  chest  have  been  given 
in  a  few  cases  only,  because  the  half-tone  shows  so  little  as  compared 
with  the  negative  that  it  is  unsatisfactory. 


no     THE    ROENTGEN   RAYS  IN   MEDICINE  AND   SURGERY 

X-Ray  Examination  of  Chest.  — There  are  two  objects  to  be  attained 
when  making  X-ray  examinations  of  the  chest.  First,  the  correct  obser- 
vation and  record  of  the  appearance  obtaining ;  this  point  has  already- 
been  touched  upon  in  Chapter  III,  and  will  be  further  discussed  in  its 
appropriate  place.  Second,  the  proper  interpretation  of  these  obser- 
vations. 


CHAPTER   V 

PULiMONARY  TUBERCULOSIS 

It  was  early  recognized  by  many  practitioners  in  various  countries 
that  the  dense  lung  in  this  disease  would  cast  a  shadow  which  might  be 
observed  on  the  fluorescent  screen.  It  seemed  to  me,  also,  that  we 
might  find  in  the  X-rays  another  means  of  recognizing  pulmonary  tuber- 
culosis in  its  earliest  stage,  and  with  this  end  in  view  I  took  every  oppor- 
tunity to  examine  early  cases  of  this  disease.  In  a  short  preliminary 
article  which  I  published  in  the  Bostoji  Medical  and  Siii'gical  Joiwnal, 
October  i,  1896,  I  find  the  following  sentence,  "I  have  examined 
about  forty  cases  of  pulmonary  tuberculosis,  and  find  not  only  that  the 
fluoroscope  is  of  value  in  determining  the  extent  of  the  disease,  but  also 
sometimes  reveals  its  location  where  and  when  it  would  otherwise  have 
been  unsuspected."  During  that  year  I  showed  that  in  pulmonary 
tuberculosis  changes  in  the  excursion  of  the  diaphragm  take  place, 
and  may  point  out  to  us  very  early  an  abnormal  condition  of  the  lung, 
and  also,  like  others,  that  the  dense  lung  in  this  disease  casts  a  shadow 
on  the  screen.  Let  us  take  up  these  signs  of  tuberculosis  in  a  little 
more  detail. 

Appearances  seen  on  the  Fluorescent  Screen  in  Pulmonary 

Tuberculosis 

Darkened  Lung.  —  The  diseased  portion  of  the  lung  or  lungs  is 
darker  than  normal,  owing  to  its  increased  density  (see  Fig.  80). 

Diaphragm  Lines. — The  diaphragm  is  restricted  on  the  affected  side 
or  sides,  and  usually  in  the  lower  part  of  its  excursion. 

Displaced  Heart.  —  The  heart  may  be  drawn  toward  the  affected  side, 
especially  during  deep  inspiration  ;  but  it  must  be  remembered  that  the 
greater  excursion  of  the  diaphragm  on  the  normal  side,  if  only  one  lung 
is  diseased,  would  contribute  to  such  a  displacement  during  full  in- 
spiration. 


112     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


.^'  f-r-ss; 


Fig.  8o.     John  H.     Cut   from  radiograph  of  tuberculous  lung.       The   lis^'litest 
involved.     See  Fig.  93  for  X-ray  tracing  of  this  patient's  chest. 


portions    are    not 


PULMONARY   TUBERCULOSIS  1 13 

Illustrative  Cases.  —  The  following  five  cases  are  illustrative  of 
the  first  two  points ;  they  are  selected  from  eighteen  cases,  some  of 
which  I  reported  at  a  meeting  of  the  Boston  Society  for  Medical  Im- 
provement, October  19,  1896,  and  all  of  which  were  published  in  the 
Medical  and  Surgical  Report  of  the  Boston  City  Hospital,  January, 
1897.  These  five  cases  were  under  the  care  of  other  physicians  and 
the  diagnosis  of  tuberculosis  had  been  established;  but  it  will  be  noticed 
that  I  was  able  by  means  of  the  X-rays  to  recognize  the  diseased  con- 
dition of  the  second  apex  before  it  was  pointed  out  by  physical  signs. 
This  observation  led  me  to  feel  more  confidence  in  the  signs  of  pul- 
monary tuberculosis,  as  indicated  by  the  X-rays,  in  those  cases  in  which 
no  other  signs  had  been  observed. 

The  following  case  ^  is  of  especial  interest  to  me,  as  it  is  one  of  the 
first  cases  of  tuberculosis  that  I  examined  with  the  X-rays.  The  patient 
was  under  the  care  of  one  of  my  colleagues  at  the  Boston  City  Hospital, 
and  was  suffering  from  tuberculosis  of  the  right  lung.  He  was  brought 
at  my  request  to  the  Massachusetts  Institute  of  Technology,  that  I 
might  examine  him  with  an  X-ray  machine  belonging  to  the  Institute. 
His  hospital  record  was  as  follows  :  — ■ 

Case  I.  January  31,  1896,  C.  B.,  aged  twenty  years.  Left  lung  neg- 
ative ;  dulness  at  right  apex,  and  just  below  this  an  area  of  tympany, 
over  which  is  heard  amphoric  breathing.  At  apex,  expiration  prolonged 
and  fine  moist  and  crackling  rales.  Dulness  in  back  nearly  to  scapula, 
with  numerous  fine,  moist  and  crackling  rales. 

April  14.  Dulness  in  upper  two-thirds  of  right  back  ;  tubular  respi- 
ration on  top  and  rather  obscure  breathing  below,  with  rather  dry  rales 
over  area  of  dulness.  Percussion  at  second  space  dull  rather  than  tym- 
panitic. Tubular  respiration  rather  more  circumscribed,  and  most 
marked  toward  anterior  axillary  line.  Fine  dry  rales,  increased  by 
cough,  extending  about  two-thirds  down. 

After  looking  at  this  patient  from  behind  for  a  moment  only,  the 
difference  in  the  amount  of  rays  which  passed  through  the  two  sides  of 
the  chest  was  very  striking,  as  seen  in  the  fluoroscope,  the  diseased  lung 
being  darker  throughout  than  the  normal  lung.  The  ribs  on  the  left 
side  were  much  more  distinct  than  those  on  the  right. 

Case  II.  B.  J.,  twenty-seven  years  old,  entered  the  Boston  City 
Hospital    September  24,    1896.      Service   of    Dr.    Sears.     Tuberculosis. 

1  "Notes  on  X-Rays  in  Medicine,"  Transactions  of  the  Association  of  American  Physicians, 
April,  1896  ;    and  "Note  on  X-Rays,"  Boston  Medical  and  Stirgicai Journal,  April  30,  1896. 
I 


114     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Tuberculous  family  history.  Haemoptysis.  During  past  month, 
dyspnoea ;  weakness ;  night  sweats ;  little  cough.  Marked  signs 
of  tuberculosis  below  second  rib  over  whole  left  side ;  right  lung 
negative. 

Exammation  with  Fluoroscope.  — Whole  of  left  lung  much  darker  than 
normal;  no  heart  outline;  no  diaphragm  outline  seen  on  left  side.  Right 
apex  also  darker  than  normal  to  lower  border  of  second  rib. 

Case  III.  L.  C,  forty-four  years  old,  entered  the  hospital  November 
21,  1896.  Service  of  Dr.  Tenney.  Tuberculosis.  Dulness,  with  rales 
over  left  side  down  to  third  rib  in  front  and  middle  of  scapula  behind. 
Has  had  haemoptyses  every  day  for  two  weeks. 

Examination  with  Fluoroscope. — Somewhat  darker  at  both  apices 
down  to  lower  border  of  third  rib,  and  to  some  extent  below;  excursion 
of  diaphragm  much  less  than  normal,  2.2  centimetres  on  right  side,  2.0 
centimetres  on  left. 

Case  IV.  H.  A.,  twenty  years  old,  entered  the  hospital  September  10, 
1896.  Patient  of  Dr.  John  L.  Ames.  Tuberculosis  (.-').  Duration  four 
weeks ;  family  history  not  tuberculous.  Medium  dry  rales  at  left  apex, 
with  slight  dulness ;  right  apex  normal. 

September  15.     Some  haemoptyses;  at  left  apex,  few  rales;  expira- 
tion prolonged  ;  breathing  higher  in  pitch. 

Examination  ivith  Fluoroscope.  —  Left  lung  extending  to  level  of 
fourth  rib  very  dark ;  also  some  involvement  of  right  apex.  The  maxi- 
mum respiratory  movement  of  the  diaphragm  on  the  left  side  is  only  2 
centimetres;  on  the  right  side  2.5  centimetres.  This  is  less  than  half 
the  normal. 

September  17.     Tubercle  bacilli  found  in  sputum. 

A  second  X-raj  examination  one  week  later  showed  the  upper  half 
of  the  right  lung  and  upper  third  of  the  left  lung  darker  than  nor- 
mal. Movement  of  the  diaphragm  the  same  as  at  the  previous 
examination. 

Case  V.  R.  J.  M.,  forty-four  years  old,  entered  the  hospital  July  16, 
1896.  Patient  of  Dr.  C.  E.  Edson.  Tuberculosis.  Anorexia;  loss  of  flesh; 
considerable  expectoration.  Dulness  at  right  apex,  front  and  back,  to 
third  space  and  middle  of  scapula ;  expiration  prolonged  ;  rales,  espe- 
cially after  cough  ;  increased  voice  sounds.     Left  side  normal. 

Examination  zvith  Fluoroscope.  —  Right  lung  darker  from  apex  to 
fifth  rib  ;  left  lung  darker  than  normal  from  apex  to  second  rib. 

Jul}'  28.    Tubercle  bacilli  found  in  sputum. 


PULMONARY   TUBP:RCUL0SIS 


115 


Appearance  of  the  Lungs  on  the  Fluorescent  Screen  in  Early  Tubercu- 
losis.—  The  apex  of  one  lung  is  seen  on  the  fluorescent  screen  to  be 
darker  than  normal,  owing  to  the  increased  density  of  this  portion  of 
the  lung ;  and,  second,  the  excursion  of  the  diaphragm  is  seen  to  be 


Fig.  81.     Diagram  of  pulmonary  tuberculosis.     Right  side. 

Right  apex  darker  and  excursion  of  diaphragm  shorter  than  normal  on  right  side.  In  the  early 
stage  the  slight  shadow  cast  is  best  detected  at  full  inspiration. 

In  this  diagram  the  apex  is  darker,  and  the  excursion  of  the  diaphragm  is  more  restricted  than 
in  the  very  early  stage  of  the  disease;  partly  for  purposes  of  illustration  and  in  the  case  of  the  apex 
also  because  it  is  difficult  to  get  a  slight  amount  of  shadow  reproduced  in  the  half-tone. 


restricted  on  the  affected  side,  and  usually  in  the  lower  part  of  its 
excursion.  The  heart  also  is  oftentimes  drawn  toward  the  diseased 
lung.  The  diagram  (Fig.  81)  indicates  the  first  two  signs  mentioned, 
but  the  shaded  area  at  the  right  apex  is  a  little  darker  than  is  found 


Il6     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

in  the  early  stages  of  the  disease,  for  two  reasons :  first,  it  is  very  difB- 
cult  to  get  a  slight  amount  of  shadow  reproduced  in  a  half-tone ;  and, 
second,  the  shadow  is  exaggerated  here  for  purposes  of  illustration. 
The  right  diaphragm  line  is  also  shortened  more  than  is  natural  in  such 
cases,  for  the  same  purpose.  In  the  early  stages  the  disease  is  rarely 
found  at  the  same  time  in  both  apices,  and  it  is  interesting  to  note  that 


C  F. 


Fig.  82.  G.  R.  Outlines  taken  from  a  case  of  very  early  tuberculosis.  Density;  darkened 
right  apex.  Diaphragm  lines  :  The  lowest  full  curved  lines  are  the  diaphragm  lines  in  deep  inspira- 
tion ;  the  two  broken  lines  above  these,  the  lines  in  the  inspiration  and  expiration  of  quiet  breathing, 
respectively;  the  dotted  lines  above  these,  the  diaphragm  lines  in  forced  expiration.  It  will  be  seen 
that  the  excursion  of  the  diaphragm  in  quiet  breathing  is  shorter  on  the  diseased  than  on  the  normal 
side,  and  that  during  expiration  the  diaphragm  ascends  higher  than  on  the  normal  side.  This  tracing 
is  given  to  indicate  that  we  should  study  the  movements  of  the  diaphragm  not  only  between  expiration 
and  deep  inspiration,  but  also  during  quiet  breathing  and  forced  expiration.     (One-third  life  size.) 


thus  far  I  have  seen  it  by  X-ray  examinations  more  often  in  the  right 
than  in  the  left  apex. 

Instead  of  the  appearances  above  mentioned  we  may  find  now  and 
then  only  a  general  diminution  in  the  clearness  of  the  lungs  and  ribs. 
This  latter  condition  probably  obtains  in  cases  where  the  disease  is 
disseminated.  It  is  not  easy  to  recognize  this  slight  departure  from  the 
normal  unless  the  physician  has  had  large  and  continuous  experience 
in  making  X-rav  examinations. 


PULMONARY   TUBERCULOSIS  117 

Appearances  seen  on  the  X-Ray  Photograph.  —  The  photograph  may 
show  a  uniformly  darkened  apex,  or  the  apex  may  have  a  mottled 
appearance,  and  this  mottling  may  extend  over  the  whole  of  the  lung 
when  it  becomes  diseased.     This  effect  is  not  so  marked  on  the  screen. 

Definition  of  Early  Tuberculosis.  —  Perhaps,  before  going  further,  it 
will  be  well  to  define  what  I  mean  by  "early"  or  "  incipient"  tuberculosis, 
as  these  terms  are  quite  indefinite  and  do  not  present  the  same  picture 
to  all  physicians.  The  words  "  incipient  tuberculosis  "  bring  to  my  mind 
a  case  like  the  following  :  A  young  person  who  has  anaemia,  irregular 
rise  of  evening  temperature  of  about  one  degree,  digestive  symptoms, 
together  with  others  of  a  general  character,  but  without  definite  signs  in 
the  lungs,  and  without  cough.  Such  patients  have  come  under  my  ob- 
servation, not  because  they  had  symptoms  pointing  directly  to  the  lungs, 
but  because  they  had  been  suffering  from  anaemia  or  rheumatism,  or  had 
recently  been  through  some  serious  illness  such  as  diphtheria.  In  many 
of  these  cases  an  abnormal  condition  of  the  lungs  was  found  in  what 
I  may  call  an  accidental  way.  For  example,  while  making  an  X-ray 
examination  of  a  patient  who  had  a  weak,  rapid  heart  after  diphtheria, 
in  order  to  determine  the  size  of  this  organ,  I  found  a  sHght  shadow  at 
one  apex  and  a  shortened  excursion  of  the  diaphragm  on  that  side. 
The  tuberculin  test  confirmed  the  signs  obtained  by  the  X-ray  examina- 
tion. My  suspicion  of  the  presence  of  this  disease  —  a  suspicion  after- 
ward confirmed  —  has  often  been  aroused  by  these  signs,  discovered 
during  an  X-ray  examination  of  the  heart,  when  my  attention  was  not 
at  the  time  of  that  examination  particularly  directed  to  the  lungs.  It  is 
obvious  that  if  the  physical  signs  are  slight  and  the  patient  is  complain- 
ing of  some  other  than  a  pulmonary  trouble,  the  presence  of  tubercu- 
losis of  the  lungs  in  its  earliest  stages  may  be  overlooked  if  only  the 
ordinary  methods  are  used.  Therefore,  in  cases  which  are  open  to 
suspicion,  an  X-ray  examination  should  be  made. 

The  number  of  patients  in  whom  I  have  detected  the  first  signs  of 
this  disease  by  the  X-rays  during  the  last  five  years  is  such  that  I  have 
been  much  impressed  with  the  advantage  which  this  examination  may  be 
to  young  persons  who  have  a  tuberculous  family  history,  and  who  are  run 
down,  but  have  slight  or  no  physical  signs  of  tuberculosis  in  the  lungs. 

Directions  for  making  X-Ray  Examinations.  —  In  tuberculosis, 
especially  in  its  early  stage,  and  in  fact  in  all  examinations  of  the  chest 
with  the  fluorescent  screen,  the  apparatus  should  be  provided  with  an 


IlS     THE    ROKNTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

adjustment  which  will  allow  the  physician  to  increase  or  diminish  the  light 
while  observing  the  appearances  on  the  screen  ;  because  certain  appear- 
ances which  will  show  clearly  in  one  light  will  be  lost  if  the  light  is 
stronger  or  weaker  than  that  best  adapted  for  giving  them  prominence. 
The  general  directions  as  to  the  disposition  of  tube,  screen,  and  patient, 
and  the  methods  for  recording  the  observations  made,  have  already  been 
given  in  Chapter  III,  therefore  it  is  unnecessary  to  consider  them  fur- 
ther here.  We  will  suppose  the  patient  lying  on  the  stretcher  in  the 
proper  position,  with  a  large  screen  30  x  35  centimetres  (12  x  14 
inches)  placed  on  his  chest. 

Diaphragm  Lines.  —  The  excursion  made  by  the  diaphragm  in  quiet 
breathing  should  be  noted,  and  the  point  to  which  this  muscle  rises  in 
inspiration  and  expiration,  on  both  sides  of  the  chest,  should  be  traced 
on  the  skin  or  the  celluloid  covering  the  screen,  according  to  the  method 
adopted.  The  patient  should  then  be  asked  to  take  a  full  breath,  and 
the  point  to  which  the  diaphragm  descends  should  be  noted  ;  the  first 
full  inspiration  should  be  followed  by  two  or  three  more,  and  the  lowest 
point  of  the  diaphragm  again  noted,  for  it  sometimes  happens  that  the 
muscle  will  descend  to  a  lower  position  on  one  or  both  sides  after  a  few 
full  inspirations  have  been  taken  than  at  first.  Next,  the  point  to 
which  the  diaphragm  ascends  in  forced  expiration  should  be  recorded. 
By  making  these  several  observations  we  sometimes  iind  that  one  set 
of  measurements  corroborates  or  supplements  the  other ;  for  instance, 
where  the  excursion  of  the  diaphragm  from  expiration  to  deep  inspira- 
tion is  shortened  on  one  side,  we  often  find  the  excursion  during  quiet 
breathing  is  diminished  also  on  this  side ;  or  that  the  diaphragm  rises 
much  higher  than  normal,  during  forced  expiration,  above  the  line  of 
quiet  expiration  on  this  side  (see  Fig.  82). 

When  one  lung  is  diseased  in  whole  or  in  part,  some  suggestion  of 
the  amount  of  disease  present  may  be  obtained  not  only  by  noting  the 
excursion  of  the  diaphragm  on  the  abnormal  side,  but  also  that  on  the 
well  side  during  quiet  breathing ;  the  normal  excursion  during  this 
period  of  respiration  is  about  1.25  centimetres  (see  page  108,  Intro- 
duction to  Thorax),  but  this  excursion  is  increased  if  one  lung  is  obUged 
to  do  more  than  its  share  of  the  work. 

Darkened  Apex.  —  The  lungs  should  be  carefully  observed,  particu- 
larly the  apices.  The  darkened  areas  seen  on  the  screen  should  be 
indicated  on  the  skin  or  celluloid.  These  areas  may  be  more  evident 
during  full  inspiration  than  during  expiration.     To  detect  the  shaded 


PULMONARY   TUBERCULOSIS 


119 


apex  it  is  necessary  for  the  physician  to  compare  the  brightness  of  the 
two  apices  and  to  observe  the  comparative  distinctness  with  which  the 
clavicle  and  the  first  and  second  ribs  stand  out  in  contrast  to  the  lighter 
intercostal  spaces  on  the  two  sides  of  the  chest.  These  comparisons 
should  be  made  during  both  inspiration  and  expiration,  and  with  the 
light  so  adjusted  that  the  suspected  side  is  barely  illuminated.  With 
the  hght  thus  regulated,  even  a  slight  difference  in  brightness  on  the 
normal  side  would  be  more  marked,  because  under  these  circumstances 
the  contrast  between  the  two  apices  would  be  greatest.  That  is  to  say, 
with  the  light  such  that  in  full  inspiration  there  is  very  little  or  almost 
no  light  coming  through  a  suspected  apex,  the  greater  brightness  of  the 
normal  apex  is  more  apparent.  In  many  cases  the  slightly  darkened 
apex  is  easily  recognized,  while  in  others,  by  careful  adjustment  of  the 
light,  —  turning  it  up  or  down  during  the  various  stages  of  respiration,  — 
the  practised  eye  will  see  that  there  is  undoubtedly  a  difference  in  the 
amount  of  light  coming  through  the  two  apices.  In  the  cases  where 
both  apices  are  slightly  diseased,  the  recognition  of  this  slight  increase 
in  density  is  more  difficult,  as  then  the  physician  must  compare  the 
brightness  as  found  in  the  apices  with  his  mental  picture  of  what  it 
should  be  for  an  individual  of  that  build ;  for,  as  already  indicated,  in 
very  stout  persons  the  lungs  would  not  be  normally  quite  as  bright  as 
in  thinner  people.  In  the  early  stages,  however,  as  mentioned  above, 
the  disease  very  rarely,  if  ever  begins,  in  both  apices  at  the  same  time, 
and  if  it  has  progressed  so  far  as  to  affect  both  apices  its  presence  would 
be  very  evident. 

General  Diminution  in  Clearness  of  Chest  Outlines.  —  The  thorax 
should  be  carefully  examined  to  determine  whether  or  not  there  is  a 
general  diminution  in  the  amount  of  light  coming  through  the  chest 
as  a  whole.  If  the  light  is  only  slightly  diminished,  this  diminution  is 
only  recognized  after  the  practitioner  has  gained  experience  by  examin- 
ing persons  of  various  sizes  and  different  ages. 

Bronchial  Glands.  —  In  some  cases  of  pulmonary  tuberculosis  we 
may  be  able  to  recognize  the  shadows  of  the  hypertrophied  bronchial 
glands.  This  is  another  indication  of  disease  to  be  looked  for  on  the 
fluorescent  screen. 

Position  of  Heart.  —  The  position  of  the  heart  should  be  examined 
and  noted  (see  chapter  on  Heart  for  methods  of  examination). 

Second  X-Ray  Examination.  —  A  second  X-ray  examination,  at  least, 
should  be  made  after  an  interval  of  several  days.     If  the  above  men- 


I20    THE    ROENTGEN    RAVS    IN    MEDICINE    AND    SURGERY 

tioned  signs  persist,  the  physician  should  be  diligent  in  his  search  for 
other  indications  of  tuberculosis,  which  will  only  too  frequently  be  found 
to  develop  later. 

Comparison  between  the  Value  of  the  Fluorescent  Screen  and  X-Ray 
Photograph  in  Early  Tuberculosis.  —  In  order  to  compare  the  results 
obtained  by  an  X-ray  photograph  of  the  chest  with  the  appearances  as 
determined  by  means  of  the  fluorescent  screen,  I  have  used  both  methods 
of  examination  in  some  cases,  in  the  same  patient,  in  an  early  stage  of 
the  disease.  I  made  this  experiment  in  the  early  stage  advisedly,  because 
in  the  later  stages  we  have  so  many  ways  of  making  a  diagnosis  that 
X-ray  examinations  are  only  useful  in  determining  the  progress  or  the 
extent  of  the  disease.  In  some  of  the  patients  in  whom  I  have  found 
signs  in  the  apex  of  one  lung  with  the  fluorescent  screen,  the  photograph 
also  showed  that  the  same  apex  was  darker  than  the  one  on  the  other 
side.  On  the  other  hand,  in  certain  cases  where  I  found  signs  by  the 
fluorescent  screen.  X-ray  photographs  showed  no  difference  between  the 
two  sides.  While  the  X-ray  photographs  show  clearly  that  the  lungs 
are  denser  than  normal  when  the  disease  has  passed  the  very  earliest 
stage,  thus  far  I  have  been  able  to  detect  an  abnormal  condition  of 
the  lungs  in  early  tuberculosis  better  by  means  of  the  fluorescent  screen 
than  by  means  of  the  photograph.  The  screen  is  a  readier  and  more 
certain  test.  This  result  has  been  a  surprise  to  me,  as  I  supposed  the 
photograph  would  prove  to  be  the  better.  Instantaneous  photographs 
can  now  be  taken  of  the  lungs  by  means  of  intensifying  screens  ;  this 
method,  which  has  been  used  by  Van  Ziemssen  and  Rieder,  and  others, 
is  discussed  in  the  Appendix. 

Usual  Means  of  Diagnosis.  —  In  this  disease,  as  in  many  others,  we 
derive  the  data  for  a  diagnosis  from  various  sources.  The  personal  and 
family  history  of  the  patient  must  be  considered  ;  then  his  general  condi- 
tion, that  is,  whether  or  not  he  has  lost  in  weight  or  strength,  has  or  has 
not  anaemia,  indigestion,  a  daily  rise  in  temperature,  or  a  rapid  pulse, 
etc.  Only  one  or  two  of  these  symptoms  may  be  present  in  any  one 
case,  however,  and  they  may  be  due  to  other  causes  than  tubercle 
bacilli.  As  the  disease  progresses,  signs  referable  to  the  respiratory 
system  appear,  such  as  increase  in  the  expiratory  sounds  and  in  tactile 
fremitus ;  the  throat  is  affected ;  there  is  morning  cough  ;  or  haemop- 
tyses ;  dulness ;  rales,  etc.  But,  as  already  indicated,  many  of  the  gen- 
eral symptoms  are  common  to  other  diseases,  and  likewise  some  of  the 


PULMONARY   TUBERCULOSIS  121 

local  signs.  The  finding  of  tubercle  bacilli  in  the  sputa  establishes 
the  diagnosis,  or  the  tuberculin  test  may  be  used. 

Early  physical  signs  at  the  right  apex,  —  namely,  increase  in  respi- 
ratory murmur  or  in  tactile  fremitus  ;  slight  dulness,  etc.  It  is  true  that 
tuberculosis  frequently  begins  at  the  right  apex,  but  there  is  often  in 
health  an  increase  in  the  respiratory  murmur  on  the  right  side  as  com- 
pared with  the  left.  There  may  also  be  an  increase  in  tactile  fremitus, 
or  a  slight  dulness  on  the  former  side  as  compared  with  the  latter. 
Therefore  these  slight  physical  signs  at  the  right  apex  have  less  value 
than  they  otherwise  would  have.     This  point  will  be  taken  up  again  later. 

The  TiibcrcnUn  Test.  —  If  we  use  the  tuberculin  test  as  a  guide 
where  the  general  symptoms  suggest  tuberculosis,  we  shall  employ  it  in 
many  cases  where  this  disease  is  not  present.  On  the  other  hand,  if 
tuberculosis  does  exist,  but  is  in  an  early  stage,  it  may  be  overlooked 
unless  more  than  one  dose  is  given.  For  example,  in  the  early  stages 
patients  do  not  react  to  one  milligramme  of  tubercuhn  ;  sometimes  not  to 
five  ;  or  perhaps  not  even  to  larger  amounts.  We  are  obliged,  then,  in 
using  tuberculin,  to  give  it  to  many  patients  who  prove  not  to  have 
tuberculosis,  and  to  give  it  to  them  a  number  of  times  to  prove  or  dis- 
prove the  tentative  diagnosis,  because  we  are  not  justified  in  inferring 
that  tuberculosis  is  absent  when  there  is  no  reaction  to  a  small  dose. 
Likewise  if  a  second  or  third  injection  is  required,  there  should  be  an 
interval  of  several  days  between  the  injections,  and  therefore  time  is 
consumed. 

Great  care  is  required  to  carry  out  the  tuberculin  test,  and  experience 
to  interpret  its  results,  for  it  may  not  be  easy  to  decide  whether  the 
effects  produced  should  or  should  not  be  interpreted  as  a  reaction. 

Further,  some  physicians  are  unwilling  to  use  this  test,  partly 
because  no  reaction  may  follow  until  several  injections  have  been  made, 
and  partly  because  other  diseases  react  to  tuberculin.  Likewise,  there 
are  many  patients  who  will  not  permit  its  use. 

Again,  even  if  the  patient  reacts  to  tuberculin,  the  test  does  not 
locate  the  lesion  nor  give  its  extent.  It  may  be  a  pulmonary  tubercu- 
losis or  a  tuberculosis  of  some  other  part  of  the  body  ;  the  test  does  not 
show  whether  or  not  the  lungs  are  involved.  The  seat  of  the  disease 
is  of  course  of  importance  in  treatment  —  a  patient  with  tuberculosis  of 
the  foot  need  not  be  sent  to  Colorado. 

Test  for  Tubercle  Bacilli.  —  In  the  early  stage  of  the  disease  there  is 
usually  no  expectoration,  therefore  this  test  cannot  be  employed ;  and 


122     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

even  in  cases  where  there  is  expectoration  the  bacilli  are  not  always 
found  when  looked  for.  It  sometimes  happens  that  five  or  six  negative 
examinations  are  made.  I  recall  one  patient  who  was  examined  six  times 
with  a  negative  result,  but  reacted  well  to  three  milligrammes  of  tuber- 
culin. In  some  cases  no  bacilli  are  found  during  the  whole  course  of 
the  disease,  but  are  found  at  the  post-mortem  examination. 

X-Ray  Examinations  as  an  Aid  in  the  Early  Diagnosis  of 
Tuberculosis.  —  This  method  gives  us  a  new  aid  m  the  early  diagnosis 
of  tuberculosis,  and  one  which  is  without  risk  or  discomfort  to  the  patient. 
Even  if  we  decide  to  use  the  tuberculin  test  it  is  well  to  precede  its  use 
by  an  X-ray  examination  in  order  to  determine  the  extent  of  the  disease 
in  the  lungs,  to  estimate  how  much  it  would  be  wise  to  give,  and  to  avoid 
the  risk  of  giving  too  large  a  dose  of  tuberculin.  The  X-ray  examination 
may  make  the  tuberculin  test  superfluous.  I  find  its  use  less  and  less 
necessary  as  my  experience  with  X-ray  examinations,  used  in  connection 
with  other  methods  of  examination,  increases.  I  say  "  in  connection  with 
other  methods  of  examination  "  advisedly.  For  example,  we  may  find 
slight  or  doubtful  signs  in  one  lung  by  auscultation  and  percussion,  sug- 
gestive of  tuberculosis,  and  if  the  X-rays  give  evidence  confirmatory  of 
this  disease,  there  is  plainly  less  need  for  the  use  of  the  tuberculin  test 
than  there  would  otherwise  have  been,  or  it  may  not  be  required  at  all. 
On  the  other  hand,  the  X-rays  may  be  of  service  in  pointing  out  the 
cases  in  which  the  tuberculin  should  be  used,  that  is,  cases  where  this 
test  is  the  only  means  of  confirming  the  diagnosis  suggested  by  the 
X-rays. 

Diagnosis  not  made  by  X-Rays  Alone.  —  By  X-ray  examinations  we 
detect  abnormal  conditions  of  the  lungs,  their  change  in  density,  elas- 
ticity, and  volume  ;  and  to  some  extent  they  assist  us  to  make  a  differ- 
ential diagnosis,  as  will  be  seen  later  ;  but  the  shaded  apex  and  shortened 
excursion  of  the  diaphragm  seen  in  pulmonary  tuberculosis  may  also 
point  to  a  recent  pneumonia  in  the  upper  lobe,  and  the  history  of 
the  case  would  be  necessary  to  enable  us  to  discriminate  between 
this  cause  and  tuberculosis ;  or  again,  the  movement  of  the  lung  might 
be  restricted  by  a  pneumonia  with  pleurisy  which  had  caused  adhesions. 
Therefore  the  inquiry  should  be  made  as  to  whether  or  not  the  patient 
had  previously  had  pneumonia  or  pleurisy.  But  the  darkened  apex 
and  shortened  excursion  of  the  diaphragm  should  always  make  the 
physician  consider  pulmonary  tuberculosis,  and  put  him  on  his   guard 


PULMONARY  TUBERCULOSIS  123 

against  a  beginning  or  an  old  and  healed  tuberculosis.  The  history 
of  the  case,  however,  and  further  examinations,  are  necessary  to  make 
a  positive  diagnosis.  In  other  words,  the  diagnosis  of  phthisis  is  not 
made  by  the  X-ray  examination  alone,  but  it  does  give  us  early  warning 
of  a  departure  from  the  normal  in  the  lung,  which  puts  us  on  our  guard 
and  enables  us,  in  conjunction  with  the  history,  etc.,  to  make  the  diag- 
nosis, and  thus  in  many  early  cases  of  tuberculosis  to  arrest  its  prog- 
ress by  proper  care. 

The  service  which  X-ray  examinations  can  render  in  giving  early 
warning  of  tuberculosis  is  well  illustrated  by  the  following  case :  — 

C.  B.,  a  young  man,  one  of  whose  parents  died  of  tuberculosis,  was 
brought  to  see  me  in  consultation  and  for  an  X-ray  examination.  He 
had  a  history  of  recent  rapid  loss  of  flesh,  but  there  were  no  physical 
signs,  no  temperature,  no  cough,  and  the  pulse  was  not  rapid. 

The  X-ray  examination  with  fluorescent  screen  showed  a  darkened 
apex  of  one  lung  and  a  much  shortened  excursion  of  the  diaphragm 
on  the  same  side. 

Both  his  physicians  suspected  tuberculosis,  and  he  was  being  kept 
under  observation  to  see  if  any  signs  developed  in  the  lungs ;  but  as  the 
X-ray  examination  showed  that  they  were  already  present,  I  saw  no 
reason  for  delay,  and  advised  that  he  should  go  directly  where  he  could 
have  good  food  and  lead  an  out-of-door  life  for  some  months.  This 
advice  was  followed,  and  four  months  later  his  family  reported  him  as 
better  than  he  had  ever  been  in  his  life. 

I  believe  that  we  may  regard  the  successful  care  of  early  tubercu- 
losis as  dependent  largely  upon  maintaining  the  condition  and  well- 
being  of  the  patient  at  as  high  a  point  as  possible.  If  there  is  delay  in 
making  the  diagnosis,  not  only  are  time  and  money  wasted,  but  also, 
what  is  of  vital  consideration,  the  chance  of  recovery  is  greatly  lessened. 
Effectual  care  does  not  by  any  means  necessitate  a  journey  to  another 
climate,  —  although,  as  just  indicated,  it  may  be  advisable  when  possible, 

—  for  it  has  been  shown  that  even  in  some  of  the  worst  climates  con- 
sumptives do  well  under  proper  direction. 

Final  Test  Tubercle  Bacilli. — We  cannot  make  a  final  diagnosis 
of  pulmonary  tuberculosis  by  the  X-rays ;  but  if  we  exclude  the  test 
for  bacilli,  which  cannot  be  made  until  cough  and  expectoration  appear, 

—  and  even  then  the  bacilli  may  not  be  found  until  after  death,  as 
already  stated,  —  we  also  see  that  in  the  early  stage  of  the  disease 
there  is  no  test  that  is  without  question. 


124     '1""^"^    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

Importan'ce  of  Early  Diagnosis.  —  The  practical  point  then  is  the 
ability,  founded  on  the  best  evidence  available,  to  warn  patients  of 
danger  before  they  begin  to  cough,  if  possible,  for  it  is  unwise  to  wait, 
for  fear  of  making  a  mistake,  until  this  symptom  has  appeared.  It  does 
not  take  skill  in  diagnosis  to  send  the  sputum  to  the  laboratory  and 
receive  a  report  that  tubercle  bacilli  are  or  are  not  present.  But  to 
weigh  the  history,  symptoms,  and  signs.  X-ray  as  well  as  the  usual  phys- 
ical signs,  and  at  the  earliest  moment  foresee  the  probabilities  with 
considerable  certainty,  does  demand  skill  and  experience  in  pulmonary 
disease.  Very  little  harm  will  be  done  if  the  physician  now  and  then 
sends  away  a  patient  for  a  timely  vacation  because  he  suspected  early 
tuberculosis,  which  did  not  exist  —  for  if  such  suspicions  are  aroused 
the  patient  probably  needs  a  rest  for  other  causes  —  as  compared  with 
the  irreparable  injury  committed  by  keeping  patients  under  observation 
and  delaying  effective  measures  until  a  medical  student  can  make  the 
diagnosis. 

Classes  of  Cases  of  Pulmonary  Tuberculosis,  in  which  the 
X-Rav  Examination  is  of  Value.  — 

A.  As  an  Aid  in  Diagnosis. — First,  in  cases  where  there  are  no 
physical  signs,  or  where  they  are  very  doubtful. 

Second,  in  cases  where  there  are  slight  physical  signs  only. 

Third,  in  cases  where  an  accompanying  emphysema,  bronchitis, 
pleurisy,  or  pneumonia  may  disguise  the  physical  signs  of  tubercu- 
losis. 

Fourth,  in  cases  where  the  physical  signs  indicate  tuberculosis,  which 
the  X-rays  do  not  confirm. 

Fifth,  in  cases  of  tuberculosis  of  some  other  portion  of  the  body 
than  the  lungs,  to  see  if  they  are  also  affected. 

Sixth,  in  patients  between  fifteen  and  thirty  years  pf  age  where  the 
family  history  is  tuberculous.     Precautionary  X-ray  examinations. 

B.  In  Old  Lesions  of  Tuberculosis. 

C.  For  determining  Existing  Conditions  more  accurately. 

D.  In  determining  the  Progress  and  Extent  of  Disease.  —  First,  in 
cases  where  the  progress  of  the  disease  is  rapid.  X-ray  examinations 
made  at  interv^als  of  a  week  or  so  will  often  show  marked  increase  in 
the  diseased  area,  although  to  physical  signs  the  progress  is  not  so 
evident.  Second,  in  cases  where  the  progress  is  not  rapid  and  the 
patients    gain   steadily  in   weight   and    improve    in    color   and    general 


PULMONARY   TUBERCULOSIS  I  25 

condition,   and    have   no   temperature,   yet    the    X-rays    show   that  the 
disease  is  steadily  advancing. 

E.  In  determining  the  Extent  of  Disease.  —  In  cases  in  which  the 
X-rays  assist  us  to  determine  the  extent  of  the  disease  as  well  as  its 
progress,  and  enable  the  physician  to  determine  whether  the  patient 
should  or  should  not  remain  at  home. 

F.  In  Acute  Miliary  Tuberculosis. 

G.  In  showing  Cavities  in  the  Lungs. 

A.    As   AN    Aid   in    Diagnosis 

This  method  gives  us  another  means  of  learning  that  the  lungs 
are  in  an  abnormal  condition,  and  thus  diminishes  the  chance  that 
the  disease  may  be  overlooked  in  the  early  stage.  Moreover,  the  signs 
by  the  X-rays  may  be  so  decisive  in  character  as  to  demand  search 
for  other  signs  and  symptoms.  Thus  the  early  warning  given  by  X-ray 
examinations  contributes  to  prompt  and  therefore  hopeful  treatment ; 
and  the  ease  with  which  they  are  made,  so  far  as  the  patient  is  con- 
cerned, together  with  their  entire  harmlessness,  makes  them  service- 
able in  the  early  diagnosis  of  pulmonary  tuberculosis.  Let  me  illustrate 
this  point  by  the  following  cases  :  — 

First,  those  without  Physical  Signs.  — 

Case  I.  Bertha  N.,  aged  twenty  years.  Entered  my  service  at  the 
Boston  City  Hospital  February  18,  1899. 

Family  History.  —  Father  died  of  tuberculosis. 

Personal  History.  —  Typhoid  fever  eight  years  previously. 

Present  Illness.  —  Bad  cold  for  two  weeks ;  sore  throat ;  no  cough. 
Some  pain  in  mid-chest  on  deep  inspiration.  Chills  three  or  four  nights 
before  entrance.  For  past  two  days  feet  have  been  sore,  and,  soon 
after,  knees  became  swollen  and  painful.     No  vomiting. 

Physical  Examination.  —  Heart :  right  border  at  right  sternal  border  ; 
left  border  8  centimetres  to  left  of  mid-sternum.  Apex  in  fourth  space. 
Action  tumultuous ;  no  murmurs  heard  ;  pulmonic  second  accentuated. 
Lungs  :  resonance  and  respiration  good. 

Tiuo  X-ray  examinations  zvith  fluorescent  screen  showed  a  darkened 
apex  and  a  shortened  excursion  of  the  diaphragm  on  the  right  side. 

Patient  reacted  to  10  milligrammes  of  tuberculin.  Temperature 
101.2°  F. ;  malaise. 

Case  H.  T.  M.,  twenty  years  old,  entered  my  service  at  the  hos- 
pital April  21,  1897,  for  phlebitis  in  the  right  leg. 


126     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


Two 


Family  History.  —  Two  of  her  sisters  died  of  tuberculosis. 

Personal  History.  ■ —  Five  weeks  ago,  pain  in  the  right  calf, 
weeks  ago,  pain  in  left  side,  worse  on  breathing. 

Physical  Examination.  —  Heart's  area,  action,  and  sounds,  normal. 
Lungs  :  good  resonance  and  respiration  throughout.  Examination  of 
the  blood  gave  30  to  35  per  cent  of  haemoglobin,  4,300,000  red  cor- 
puscles, 9000  white  corpuscles. 


T.M. 

May    1897. 
Fe.h.    190 J. 


® 


Fig.  83.    T.M.    X-ray  tracing  (one-third  life  size).     Right  lung  shaded ;  excursion  of  diaphragm  on 
right  side  4.5  centimetres;  on  left  side  7.5  centimetres. 

May  12.  X-Ray  Examiiiation  ivith  Screen.  —  Right  lung  shaded. 
Excursion  of  the  diaphragm  on  the  right  side  4.5  centimetres,  on  the 
left  side  7.5  centimetres  (see  Fig.  83). 

May  22.  Reacted  to  5  milligrammes  of  tuberculin.  Temperature 
104.8°  F. 

JSIay  27.  Physical  examination  shows  nothing  abnormal  in  the 
lung.  Patient  has  no  cough,  is  well  developed  and  well  nourished. 
No  symptoms  pointing  to  trouble  in  the  lungs. 

June  12.  Several  careful  physical  examinations  of  the  lungs  made 
during  the  past  month  gave  no  evidence  of  tuberculous  process.  Reso- 
nance and  respiration  good.     Discharged. 

1897.     Went  home  to  Canada  and  remained  a  year. 


PULMONARY   TUBERCULOSIS 


127 


1 898- 1 899.     Had  cough  and  night  sweats  during  the  winter. 

November  23,  1899.  Unusually  well  developed  and  nourished  ;  great 
increase  in  weight,  present  weight  170  pounds.     Appears  well. 

FebruiDj,  1900.  The  patient  has  been  perfectly  well  since  Novem- 
ber, 1899.     The  X-ray  signs  remain  the  same  as  in  1897  (see  Fig.  83). 

March,  1901.  Has  been  at  work  continuously  ;  seems  now  perfectly 
well. 

Second,  Cases  where  there  are  Slight  Physical  Signs  only.  — 

Case  L  Michel  F.,  aged  twenty-four  years.  Diagnosis :  acute 
articular  rheumatism,  cardiac.  Entered  my  service  at  the  Boston  City 
Hospital  December  2,  1898.  Family  Jiistojy,  negative.  Personal  his- 
tory :  was  in  the  hospital  with  acute  articular  rheumatism  in  ankles 
and  right  wrist,  in  June,  1898,  for  two  weeks,  and  again  in  July  and 
August,  1898,  for  four  weeks.  Lungs  were  then  normal,  temperature 
such  as  might  be  expected  with  rheumatism,  not  suggestive  of  tuber- 
culosis. After  his  discharge  from  the  hospital  in  August  his  ankle 
continued  to  trouble  him,  but  he  kept  at  work  until  the  middle  of  No- 
vember. Then  both  ankles  were  painful,  and  the  right  wrist  was  also 
affected.  December  2,  1898,  says  he  has  felt  feverish  and  slept  poorly 
on  account  of  pain  ;  no  headache,  no  cough,  appetite  good.  Physical 
examination :  well-developed  and  well-nourished  man,  general  con- 
dition good.  Pulse  76.  Lungs :  resonance  and  respiratory  sounds 
normal. 

December  17.  X-ray  examination  loitli  screen  was  made  in  order  to 
determine  the  size  of  the  heart.  Heart  shows  slight  enlargement,  both 
to  the  right  and  left.  I  noticed  while  examining  this  organ  that  the 
right  lung,  from  the  apex  as  far  as  the  third  rib,  was  darker  than  nor- 
mal, and  the  excursion  of  the  diaphragm  was  diminished  on  this  side, 
being  5.25  centimetres  on  the  right  side  and  7.5  centimetres  on  the  left 
side. 

On  the  same  day  the  physical  examination  was  made  after  X-ray 
examination  :  expiration  somewhat  more  marked  in  the  right  apex  in 
front.  Tactile  fremitus  slightly  increased  in  the  right  back  between  the 
scapula  and  the  vertebral  column.  Patient  when  asked  if  he  had  not 
lost  in  weight  during  the  past  few  months,  thought  that  he  had.  De- 
cember 22,  I  milligramme  of  tuberculin  was  given  ;  no  reaction. 
December  27,  3  milligrammes  of  tuberculin  were  given  ;  no  reaction. 
December  30,  5  milligrammes  of  tuberculin  were  given  ;  reaction  well 
marked.     Temperature   102.5°  F.,  with   malaise.     December  30,  morn- 


128     THE    ROENTGEN   RAYS   IN    MEDICINE   AND   SURGERY 

ing  and  evening  temperature  for  three  weeks  had  been  98°  to  99°  F. 
No  cough  at  any  time. 

January   2,    1899.      Prolonged  expiration,    slight    increase   in  tactile 
fremitus   in   the  right  back  between   the    scapula   and  spine,   opposite 


Miche/  r 
Exir^o  Tabercuiosia 


Fig.  84.  Michel  F.,  December  17, 1898.  Diagnosis;  acute  articular  rheumatism.  X-ray  examina- 
tion with  screen  shows  that  the  apex  on  the  right  side  is  darkened.  Broken  and  nearly  horizontal  lines 
on  either  side  show  position  of  diaphragm  in  expiration  ;  the  full  lines  below,  in  forced  inspiration. 
It  will  be  noticed  that  the  excursion  of  the  diaphragm  on  the  right  side  is  shorter  than  on  the  left.  The 
heart  during  forced  inspiration  moves  more  to  the  right  than  normal,  because  the  right  lung  expands 
less  than  the  left.     (One-third  life  size.) 


the  spine  of  the  scapula.     Discharged.     His  appearance  at  this  time 
was  that  of  a  well  man. 

In  March,  1899,  this  patient  had  another  attack,  and  returned  to  the 
City  Hospital.  He  was  under  Dr.  V.  Y.  Bowditch's  care.  Diagnosis : 
rheumatism.     With  Dr.  Bowditch's  permission  I  insert  here  the  note  he 


PULMONARY   TUBERCULOSIS  129 

made  of  his  physical  examination  of  the  hmgs :  "  Percussion  note  is 
sHghtly  high  in  pitch,  and  slight  dulness  at  right  apex  to  the  third 
rib  in  front  and  spine  of  scapula  behind.  No  change  in  respiratory 
murmur  and  no  rales.  Resonance  and  respiration  good  over  balance 
of  chest." 

In  March,  1899,  I  made  another  X-ray  examination,  and  found  the 
same  darkened  area  of  the  lung  and  shortened  excursion  of  the  dia- 
phragm as  on  December  17,  1898. 

Case  IL  Michael  H.,  aged  thirty-six  years.  Entered  my  service 
at  the  hospital  March  7,  1898,  with  acute  articular  rheumatism,  which 
began  five  weeks  before  entrance  with  swelling  in  the  knee,  extended 
to  one  hip,  then  to  the  other,  then  to  the  left  ankle.  Ten  days 
before  entrance  both  hands  became  red,  swollen,  and  painful ;  five 
days  before  started  again  in  the  knee,  right  hip,  right  hand,  and  shoul- 
der. Physical  examination  of  the  lungs  showed  good  resonance  and 
respiration  throughout.  On  March  10  the  left  wrist  was  red  and 
painful.  On  March  18  this  condition  improved  under  saHcylates. 
Practically  well. 

March  8.  X-Ray  Examination  zuitJi  Screen.  —  This  was  made  to 
determine  the  size  of  the  heart,  as  I  was  then  making  X-ray  examina- 
tions of  this  organ  in  all  cases  of  acute  rheumatism.  The  apex  of  the 
right  lung  was  found  to  be  shaded  as  compared  with  the  left  lung  ; 
excursion  of  the  diaphragm  on  the  right  side  5.5  centimetres,  on  the 
left  side  8  centimetres. 

After  this  examination  auscultation  and  percussion  showed  slight 
dulness  on  the  right  side  from  the  apex  to  the  second  rib.  Tactile 
fremitus  increased,  expiration  prolonged. 

March  14.  Second  X-ray  examination  pointed  to  the  right  lung  as 
the  seat  of  the  trouble,  as  before. 

One  milligramme  of  tuberculin  given,  later  2  milligrammes  given, 
finally  4  given.  Patient  reacted  to  this  last  dose.  Discharged  April 
7,  1898. 

In  May,  1899,  he  returned  to  the  out-patient  department,  and  Dr. 
John  W.  Bartol  kindly  reported  to  me  that  he  found  no  physical  signs 
in  the  lungs. 

It  is,  of  course,  a  serious  matter  for  a  patient  or  for  his  friends  to  be 
told  that  he  has  trouble  in  the  lungs ;  but  it  is  much  more  serious  for 
the  physician  to  fail  to  make  an  early  diagnosis  and  take  prompt 
action.     Moreover,  the    natural  apprehensions  of    the   patient  may  be 


I30    THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURCxERY 

very  reasonably  allayed  by  a  hopeful  prognosis  in  view  of  the  early  dis- 
covery of  the  disease. 

Association  of  Tuberculosis  mid  Acute  Articular  Rheuniatisni.  —  It  will 
be  noticed  that  these  two  cases  had  acute  articular  rheumatism.  I  have 
been  struck  with  the  frequent  association  of  rheumatism  and  tuberculosis. 

Result  of  Physical  Exauiiuation  before  and  after  X-Ray  Examination. 
— The  physical  examination  in  some  cases  of  early  tuberculosis  has 
revealed  nothing  abnormal  to  the  physicians  examining  them  until  after 
attention  was  drawn  to  the  abnormality  of  the  lungs  by  my  X-ray 
examination.  After  this  had  been  made,  however,  auscultation  and 
percussion  over  the  site  indicated  by  the  X-rays  has  frequently  revealed 
an  expiratory  murmur  a  little  more  marked  on  this  side  than  on  the 
opposite  side.  In  some  cases,  also,  the  dulness  has  seemed  a  little  more 
prominent,  and  the  tactile  fremitus  has  been  found  to  be  slightly  in- 
creased. It  is  much  easier,  I  think,  when  the  conditions  are  very 
little  removed  from  the  normal,  to  recognize  these  slight  differences 
after  the  X-ray  examination  has  suggested  where  we  should  look  for 
them.  Again,  there  are  other  cases  where  the  tactile  fremitus,  slight 
dulness,  or  slightly  harsher  respiration  on  one  side  as  compared  with 
the  other,  may  be  within  normal  limits,  but  where  an  X-ray  examina- 
tion shows  less  doubtful  signs  of  disease. 

Early  Warning  given  and  Conditions  zvatcJied  by  the  X-Rays.  —  The 
following  case  is  given  in  some  detail  to  show  how  a  case  of  tuberculosis 
can  be  watched  on  the  fluorescent  screen,  and  the  physician  aided  to  take 
suitable  measures :  — 

Case  I.  Margaret  G.,  eighteen  years  old,  entered  my  service  at  the 
hospital  October  26,  1899.      Diagnosis:  chlorosis;  rheumatism. 

Family  History. —  Father  and  mother  living.  Mother  well.  Father 
has  had  chronic  cough  for  two  and  one-half  years ;  was  in  the  hospi- 
tal two  years  ago  for  operation  on  fistula.  During  the  first  year  of 
cough  had  occasional  night  sweats  and  haemoptyses.  Cough  of  late 
has  been  better.     Five  brothers  and  two  sisters  living  and  well. 

Personal  History.  —  Pneumonia  two  years  ago  in  left  chest.  Peri- 
tonitis same  year.  Muscular  rheumatism  eighteen  months  ago.  Cata- 
menia  at  sixteen  years  of  age,  irregular  since.  Previous  to  entrance 
patient  had  worked  in  a  book-bindery,  where  there  was  much  dust  and 
poor  air ;  was  seated  most  of  the  time ;  work  lasted  nine  hours  with  a 
varying  interval  of  from  fifteen  to  sixty  minutes'  nooning;  had  a  cold 
lunch  always.     Gives  no  history  of  cough  or  fainting    attacks.      Has 


PULMONARY   TUBERCULOSIS 


1^1 


had  much  trouble  with  eyes,  which  has  been  reheved  much  of  the 
time  by  glasses.  Does  not  think  that  she  had  lost  any  flesh  up  to 
September  i,  1899,  when  she  went  on  a  vacation  to  Milford,  N.  H., 
feeling  tired  out  and  "all  run  down,"  and  with  much  headache.  Re- 
turned to  work,  having  gained  three  pounds,  but  not  feeling  much 
better,  headache  having  continued  while  away.  Did  not  notice  that 
color  was  improved ;  did,  however,  feel  rested.  At  end  of  two  weeks 
was  forced  to  give  up  work  because  of  increasing  weakness  and  malaise. 


-@ 


Manure 

OcT   28'^   1839. 


Fig.  85.     Margaret  G.     X-ray  tracing  made  October  28,  1899.       (One-third  life  size.)      Right  apex 
darker  than  normal ;  excursion  of  diaphragm  shortened  on  right  side. 


At  this  time  was  sleeping  very  poorly  and  had  no  appetite.  From  time 
of  resuming  work  up  to  that  of  entering  the  hospital  {i.e.  five  weeks) 
had  lost  eight  pounds. 

PJiysical  examination.  —  Well  developed  and  nourished.     Anaemic. 

Eyes  :  sclera  bluish.     Pupils  dilated. 

Tongue  :  moist,  slight  coat. 

Pulse  :  regular  ;  good  volume  and  tension. 

Heart :  right  border  3  centimetres  to  right  of  median  line ;  left 
border  12  centimetres  to  left  of  same  line.     Apex  felt  in  fourth  inter- 


132 


THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 


pace,  outside  the  nipple  line.  Action  regular.  Soft,  blowing  systolic 
murmur  heard  all  over  cardiac  area  to  left  of  sternum,  loudest  in  second 
left  interspace.  Systolic  murmur  also  heard  in  base  of  left  neck. 
Pulmonic  second  slightly  accentuated. 

Lungs :  resonance  and  respiration  good  throughout  except  pro- 
longed expiratory  murmur  and  increased  tactile  fremitus  and  vocal 
resonance  at  right  apex,  front  and  back.     No  rales. 


Mar^r  C 


Fig.  86.     Margaret  G.     X-ray  tracing  made  November  6,  1899.     (One-third  life  size.)      Right  apex 
still  darker  than  normal,  and  excursion  of  diaphragm  shortened  on  right  side. 


Liver,  spleen,  and  abdomen  negative,  except  slight  dulness  at 
seventh  rib. 

Extremities :  very  slight  oedema.  Over  inner  malleolus  of  left 
limb,  redness,  swelling,  heat,  and  tenderness. 

October  28.  X-Ray  Examination  with  Screen.  —  Right  apex  dark- 
ened. Excursion  of  diaphragm  on  right  side  shorter  than  on  left  side 
(see  Fig.  85). 

November  I.     Has  improved  in  color. 

November  3.  Physical  examination  shows  prolonged  expiration  at 
right  apex.     The  increased  tactile  fremitus  at  first  noticed  is  now  absent. 


PULMONARY   TUBERCULOSIS  133 

Patient  has  better  color  and  has  apparently  gained  in  weight  and 
strength. 

November  6.     No  murmurs  heard  over  second  interspace  in   neck. 

X-ray  examination  ivith  screen  on  same  date  shows  shortened  ex- 
cursion of  diaphragm  on  the  right  side,  and  that  the  shading  at  right 
apex  persists  (see  Fig.  86). 

November  10.  Patient  appears  to  be  gaining.  Is  up  and  about  ward 
each  day.     No  cough. 

November  13.     Patient  as  at  last  note;  gains  steadily.     Has  had  two 


Mar^r  C 


Fig.  87.     Margaret  G.     X-ray  tracing  made  November  17,  1899.     (One-third  life  size.)      Right  apex 
darker  than  normal ;  excursion  of  diaphragm  shortened  on  right  side  as  compared  with  the  left. 


doses  of  tuberculin  ;  first  on  November  6,  of  i  milligramme,  and  again 
November  13,  of  3  milligrammes,  without  reaction  to  either,  except 
for  the  very  slightest  rise  in  temperature  following  the  second.  Patient 
was  given  5  milligrammes  of  tuberculin  on  the  evening  of  the  i6th, 
at  6.30  o'clock.  On  the  following  morning  face  became  flushed,  patient 
felt  chilly,  and  temperature  rose  to  102.6.  These  symptoms,  with 
severe  headache,   ceased  some  hours  after. 

November  17.    X-Ray  Examination  tvith  Screen.  —  Appearances  indi- 
cate tuberculous  process  at  right  apex,  but  no  increase  in  signs  due  to 


134 


THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


tuberculin,  from  which  .she  is  now  reacting,  it  having  been  given 
eighteen  hours  previously. 

Physical  examination  on  this  date  shows  dulness  and  increased  tac- 
tile fremitus  at  right  apex ;  expiratory  murmur  slightly  greater  under 
right  clavicle  than  under  left ;  slightly  better  resonance  at  left  apex ; 
both  sides  alike  behind  to  percussion,  and  no  increase  of  tactile  fremitus ; 
both  backs  normal.     Aortic  second  slightly  accentuated. 

A^ovcmbcr  21.  Patient  weighed  to-day  in  same  clothes  as  worn  on 
entrance;  has  gained  one-half  pound;  weighs  106.]  pounds. 


Temperatlre 

Pulse 

Morning 

Evening 

Morning 

Evening 

Oct.  26 

"      27 

"■      28 

'■      -9 

'•      30 

'•      3' 

Nov.    I 

99-5 
100. 1 
100.8 

99-5 
98.4 

99 
98.2 

100. 1 

102.2 

IOI.2 

100.8 

100 

100.2 

99 
89.5 

72 
102 

no 
106 

95 
78 
82 

82 

102 
108 

no 
98 
88 
88 
88 

Respirations  were  between  20  and  24. 

After  November  3  her  temperature  was  normal  until  November  28, 
1899,  when  she  was  discharged. 

November  28.  Physical  examination  was  as  follows ;  expiratory 
murmur  slightly  more  marked  under  the  clavicle  at  the  right  apex,  with 
the  Bowles  stethoscope ;  no  dulness  at  either  apex.  Behind,  above 
the  spine  of  the' scapula  on  the  right  side,  and  between  it  and  the  spinal 
column,  the  expiratory  murmur  with  the  stethoscope  was  rather  more 
marked  than  on  the  left  side.  Above  the  clavicle  on  the  right  side, 
the  expiratory  murmur  was  rather  more  marked  than  on  the  left. 

{^Examination  of  Right  Apex  iti  Patients  wJiose  Lnngs  zvere  presum- 
ably Normal.  —  The  X-ray  examination  of  this  patient  had  directed  my 
attention  strongly  toward  the  right  apex,  and  as  this  apex  differs  nor- 
mally from  the  left,  it  occurred  to  me  to  compare  the  two  apices  in 
several  patients,  in  whom,  so  far  as  known,  there  was  no  pulmonary 
disease,  in  order  to  better  decide  how  much  weight  should  be  given  to 
the  physical  signs  on  the  right  side.     On  this  same  morning  (Novem- 


PULMONARY  TUBERCULOSIS 


135 


ber  28),  therefore,  I  examined  carefully  four  other  patients  in  my  wards, 
with  a  view  to  making  the  above  comparison. 

James  D.,  a  boy  fifteen  years  old,  convalescent  from  typhoid  fever, 
had  dulness  at  the  right  apex,  and  expiration  more  marked  than  at  the 
left  apex. 

Benjamin  C,  twenty-five  years  old  :  the  right  apex  in  front  was  dull 
as  compared  with  the  left ;  tactile  fremitus  increased,  and  respiratory 
murmur  more  marked. 

James  T.,  fourteen  years  old,  convalescent  from  typhoid  fever;  right 
side  in  front  slightly  duller  than  left ;  expiratory  murmur  more  marked 
in  the  right  front  below  clavicle  than  on  the  left  side. 

Roy  W.,  fourteen  years  old,  arthritis  of  knee  joints  :  percussion  note 
slightly  increased  at  the  right  apex ;  tactile  fremitus  the  same  on  both 
sides ;  expiratory  murmur  more  marked  at  the  right  apex  in  front  than 
over  the  same  area  on  the  left.  X-ray  examination  of  this  patient  on 
this  morning  showed  the  lungs  to  be  perfectly  clear.] 

December  19,  1899.  The  patient,  Margaret  G.,  was  admitted  to  Dr. 
Trudeau's  Sanitarium  in  the  Adirondacks,  and  remained  there,  through 
his  kindness  and  that  of  a  friend,  until  about  April  i.  She  was  then  so 
well  that  Dr.  Trudeau  was  willing  she  should  return  to  her  work. 

The  report  of  her  case  made  at  the  Sanitarium  is  given  below  :  — 

"  M.  G.,  admitted  December  19,  1899.     Dr.  Williams. 

''  Family  History.  —  Father  has  been  suffering  with  pulmonary  tuber- 
culosis for  past  five  years.     Mother  frequently  has  articular  rheumatism. 

''Personal  History.  —  Measles  during  childhood.  'Inflammation  of 
bowels '  three  years  ago.  Pneumonia  two  years  ago,  from  which  she 
entirely  recovered.  Has  led  an  indoor  life  for  past  four  years.  Occa- 
sionally has  attacks  of  articular  rheumatism,  last  attack  six  weeks  ago. 

"  Present  Illness.  —  Knew  nothing  of  her  pulmonary  trouble  until  it 
was  discovered  upon  her  admission  to  the  Boston  City  Hospital  for  acute 
articular  rheumatism  and  chlorosis.  Had  lost  weight  rapidly  before 
her  admission  to  hospital,  and  had  dyspnoea  upon  exertion.  No  cough, 
expectoration,  or  sweats.  Has  had  pain  over  right  apex  for  past  four 
weeks. 

"  Present  ConditioJi.  —  Fairly  well  nourished  ;  not  particularly  anae- 
mic ;  no  cough,  very  occasional  expectoration ;  no  dyspnoea  ;  feels  as  well 
as  ever.  Has  gained  in  weight  since  she  left  the  hospital,  pain  in  right 
apex  being  all  of  which  she  complains. 


136    THE   ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

"  December  20.  Physical  Examination.  —  Inspection :  negative  ex'cept 
for  slightly  lessened  expansion  on  right. 

"  Palpation  :  negative. 

"  Percussion  :  no  impairment  of  resonance. 

"  Auscultation :  some  loss  of  vesicular  murmur  at  right  apex,  with 
fine  dry  pleuritic  sounds  and  few  fine  dry  crepitations. 

"  Heart :   no  signs  of  endocarditis. 

"  February  i o.  Physical  Exainination  (by  Drs.  Trudeau  and  Williams). 
—  Prolonged  expiration  at  right  apex,  with  a  few  fine  dry  crepitations. 
Some  weakness  of  breathing  at  left  apex. 

"Sputum  :  tubercle  bacilli  found  December  24,  1899. 

"  Urine :  negative. 

"Weight:  present,  io6|^;  normal,  113.     March  i,  1900,  120  pounds. 

^^  March  16,  1900.  Cough  and  expectoration  have  entirely  dis- 
appeared." 

April  5.  X-ray  examination  ivitJi  screen  after  return  from  the  Sani- 
tarium. The  following  cut  shows  the  appearances  I  found  in  the  chest 
after  her  return  from  the  Sanitarium.     They  were  nearly  normal. 


viar^r  G 


Fig. 


Margaret  G.    X-ray  tracing  made  April  5,  1900.     (One-third  life  size.)     Chest  nearly 
normal. 


PULMONARY  TUBERCULOSIS 


^Z7 


May  I.  The  patient  caught  a  cold,  which  lasted  about  ten  days, 
that  was  accompanied  by  some  cough  and  expectoration  night  and 
morning.     She  came  to  see  me  on  May  21. 

May  2 1 .  X-Ray  Exaviiiiation  with  Screen.  —  The  following  cut  shows 
the  result  of  this  examination.  The  right  apex  was  slightly  shaded,  and 
the  excursion  of  the  diaphragm  was  shortened  on  the  same  side. 

Physical  Examination.  —  Very  slight  dulness  over  the  right  clavicle, 
that  is  to  say,  there  was  a  sHght  difference  between  the  two  apices,  but 
as  already  shown  there  may  be  normally  a  little  difference  between  them. 

Temperature  at  3  p.m.  99.6;  pulse  72;  respiration  24. 


Fig.  89.     Margaret  G.     May  21,  1900.    X-ray  tracing.     (One-third  life  size.)     Right  apex  shaded; 
excursion  of  diaphragm  shortened  on  this  side. 


In  consequence  of  the  conditions  found  by  this  examination,  the 
patient,  through  the  kindness  of  a  friend,  was  sent  back  to  the  Sani- 
tarium in  June,  1900. 

February  11,  1901.     X-Ray  Examination  zvitJi  Scj-een.  —  See  Fig.  90. 

Temporary  conditions  in  the  lungs  may  be  followed  by  means  of 
X-ray  examinations  in  some  cases.  For  example,  if  a  patient  who  has 
slight  pulmonary  signs  takes  a  bad  cold,  owing  to  some  exposure,  the 
X-rays  may  show  a  shortened  excursion  of  the  diaphragm  and  a  more 


138     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

marked  darkness  at  the  site  of  the  disease.  These  signs  will  be  seen  to 
improve  at  subsequent  examinations  as  the  patient  recovers  from  the 
cold  ;  if  they  persist,  a  renewal  of  the  treatment  is  demanded. 


MargtG- 

Feb.  11^1901. 


o 


Fig.  90.  Margaret  G.  Returned  to  the  Adirondack  Sanitarium  in  June  and  remained  there  four 
months  more;  she  came  back  in  excellent  condition.  My  last  X-ray  examination,  with  screen,  Feb- 
ruary, 1901,  gave  the  above  results.     (One-third  life  size.) 


Case  II.  F.  A.,  nine  years  old.  Schoolboy.  Entrance  diagnosis: 
typhoid  fever.     Entered  my  service  at  the  hospital  November  14,  1898. 

Family  history  good. 

Pcrsojial  History.  —  Had  diphtheria  three  years  ago,  otherwise  has 
always  been  well.  For  the  past  month  has  felt  poorly ;  went  to  bed  a 
week  ago ;  complains  of  pain  in  the  epigastrium  and  in  front  of  chest. 
Has  headache  and  feeling  of  weakness.  Appetite  poor  and  sleeps 
poorly.  No  chills,  no  nosebleed,  no  cough.  Well-developed  and  well- 
nourished  boy  in  excellent  general  condition.  Color  good.  Had  at 
entrance  a  temperature  of  100°;  pulse  108,  regular  and  rather  weak. 
Enlargement  of  the  spleen,  questionable  ;  no  rose  spots.  Serum  reaction 
negative.  Liver  dulness  from  sixth  rib  to  one  finger's  breadth  below 
costal  border. 

Lungs  :  in  right  apex  in  front  and  behind  there  is  an  increase  in  vocal 


PULMONARY   TUBERCULOSIS 


139 


resonance  and  fremitus  and  whispered  bronchophony.  Lungs  otherwise 
normal.     No  change  in  percussion  note  and  no  rales  heard. 

Xoveinbo'  18.  By  percussion  over  the  heart  its  area  was  found  to 
be  increased  to  the  right,  but  in  a  few  days  this  enlargement  disap- 
peared. The  temperature  had  run  a  slightly  elevated  course,  99°  morn- 
ing, 100°  evening,  for  some  days;  this  is,  I  think,  very  suggestive  of 
tuberculosis. 

November  22.  X -Ray  Exainimxtion  zvitJi  Screen. — The  right  lung 
above  the  fourth  rib  not  so  bright  as  left.  Excursion  of  diaphragm 
shorter  and  higher  up  on  right  side  than  on  left  side,  3  centimetres  on 
the  former,  5  centimetres  on  the  latter.     Heart  displaced  to  right. 

Novejiiber  27.     One  milligramme  of  tuberculin  given.     No  reaction. 

December  i.  Three  milligrammes  of  tuberculin  given  at  6  p.m.  The 
following  day  at  11  a.m.,  temperature  102.5'^;  marked  malaise. 

December  3.  Second  X-ray  examination  ten  days  after  first ;  signs 
corresponded  with  those  of  the  first  examination. 

December  5.  Was  discharged,  having  been  up  and  about  the  ward 
for  some  time.  General  condition  good.  No  cough,  and  appears  per- 
fectly well.  Sleeps  well ;  appetite  good  ;  color  excellent.  This  patient 
was  in  the  hospital  eighteen  days  under  careful  observation. 

Unfortunately,  the  parents  could  not  be  made  to  realize  that  the  boy 
was  not  perfectly  well,  and  therefore  the  directions  I  gave  them  were 
not  carried  out. 

On  February  27,  1899,  he  came  to  me  for  another  X-ray  examination. 
I  found  the  upper  portion  of  the  right  lung  darker  than  the  left,  and  the 
excursion  of  the  diaphragm  on  the  right  side  3  centimetres,  on  the  left 
side  4.7  centimetres.  There  was  some  dulness  by  percussion  over  the 
upper  portion  of  the  right  lung  in  front.  His  condition  was  not  as 
good  as  when  I  saw  him  in  December  ;  he  looked  a  little  pale. 

Some  months  later  the  boy's  loss  of  health  and  strength  became  evi- 
dent to  the  parents,  and,  appreciating  that  he  was  really  ill,  they  removed 
to  better  quarters  in  the  outskirts  of  Boston,  and  carried  out  as  well  as 
they  could  the  advice  I  had  given  them. 

September,  1900.     The  patient  is  much  improved. 

Incipient  Pulmonary  Tuberculosis.  —  I  have  seen  thus  far  over  thirty 
cases,  where  there  were  slight  or  no  physical  signs,  in  which  X-ray 
examinations  showed  signs  of  pulmonary  tuberculosis.  In  all  of  these 
cases  the  X-ray  examination  was  confirmed  by  finding  the  tubercle 
bacilli   or   by   the  tuberculin   test.     In  twenty-two  cases   I    have  made 


I40   thf:  roentgen  rays  in  medicine  and  surgery 

the  diagnosis  of  incipient  pulmonary  tuberculosis  by  means  of  X-ray 
examinations  in  conjunction  with  other  indications  of  tuberculosis,  such 
as  one  or  more  of  the  following  :  haemoptysis,  loss  in  flesh,  morning 
cough,  night  sweats,  evening  rise  in  temperature,  slight  physical  signs. 
In  these  cases  the  diagnosis  was  not  confirmed  by  finding  the  tubercle 
bacilli,  and  the  tuberculin  test  was  not  used ;  therefore  I  do  not  ask 
others  to  accept  the  diagnosis. 

Added  Evidence  from  X-Ray  Examination.  —  The  following  case  is 
illustrative  :  — 

Case  I.  George  S.  B.,  teacher,  thirty-two  years  of  age.  Lost  his 
mother  and  one  brother  by  tuberculosis.  Haemoptysis,  June  5,  1897. 
In  Dr.  Folsom's  service  in  Boston  City  Hospital  for  ten  days.  Nothing 
found  in  his  chest.  Subsequently  to  June  had  several  slight  hemor- 
rhages. In  July  Dr.  M.  P.  Smithwick  found  a  few  small  rales  above 
the  right  clavicle. 

September  17.  Dr.  Smithwick  found  no  rales  at  right  apex,  but 
thought  he  found  a  few  in  the  right  axilla  ;  otherwise  there  were  no 
physical  signs.  No  rise  in  temperature ;  no  tubercle  bacilli  found, 
though  the  sputa  had  been  examined  several  times.  Dr.  Smithwick 
brought  the  patient  to  see  me  on  September  17. 

September  17.  X-Ray  Examination  zvitJi  Screen.  —  Right  apex  to 
lower  border  of  second  rib  was  darker  than  the  left  apex.  Excursion  of 
the  diaphragm  on  right  side  3.5  centimetres,  on  left  side  6  centimetres. 
This,  together  with  what  had  gone  before,  led  me  to  state  that  I  had 
little  doubt  the  patient  had  tuberculosis. 

October  3.    Dr.  Smithwick  found  tubercle  bacilli. 

This  patient  went  West  and  in  April,  1901,  was  doing  well. 

Early  Indications  by  X-Rays  ftirtJier  emphasi::ed ;  Involvement  of 
Second  Apex.  —  In  many  cases  where  the  disease  was  indicated  in  but 
one  lung  by  the  usual  signs,  I  have  been  able  to  recognize  it  by  the 
X-rays  in    both  lungs. 

Third.  Association  of  Tuberculosis  and  Some  Other  Disease.  — When 
tuberculosis  is  associated  with  another  disease,  as  with  emphysema, 
bronchitis,  or  pleurisy  with  effusion,  its  presence  may  be  unsuspected, 
or  may  not  be  readily  recognized  by  the  ordinary  methods  of  examina- 
tion;  here  again  the  X-rays  are  of  value  in  aiding  us  to  make  a 
more  complete  diagnosis. 

a.  Tuberculosis  with  Emphysema.  —  The  increased  density  in  the 
lung  due  to  tuberculosis  may  be  so  obscured  by  emphysema  that  it  is  not 


PULMONARY   TUBERCULOSIS 


141 


recognized  by  physical  signs,  but  this  emphysematous  condition  offers 
no  obstacle  to  the  X-ray  examination.  On  the  contrary,  it  is  rather 
helpful,  inasmuch  as  the  increased  brightness  in  the  chest  due  to  this 
condition  brings  out  the  darkened  tuberculous  part  of  the  lung  by 
heightening  the  contrast  that  obtains  under  ordinary  conditions.  The 
helpfulness,  then,  of  the  X-ray  examination  when  tuberculosis  and  emphy- 
sema are  both  present,  is  two-fold  :  it  may  not  only  enable  us  to  recognize 
tuberculosis  when  by  physical  signs  it  is  undetected,  but  also  to  make  a 
diagnosis  of  emphysema  which  had  previously  not  been  suspected  on 
account  of  the  tuberculosis  from  which  the  patient  was  suffering. 

The  following  case  shows  that  the  presence  of  emphysema  and 
tuberculosis  may  be  learned  and  suggested  respectively  by  an  X-ray 
examination,  and  sometimes  in  patients  where  neither  had  been  sus- 
pected. A.  B.  entered  the  hospital  with  a  diagnosis  of  malaria.  There 
was  a  history  of  haemoptyses  seven  years  previously.  The  X-ray  exami- 
nation show^ed  signs  of  emphysema  and  a  darkened  right  apex.  After 
this  dark  apex  had  been  pointed  out  by  the  X-rays,  the  physical  signs 
noted  were  as  follows  :  Heart  area  normal.  Lungs  :  good  resonance 
over  all ;  slight  increase  in  vocal  fremitus  at  right  apex  front  and  back, 
perhaps  within  normal  limits ;  expiration  prolonged  at  right  apex ; 
whispered  bronchophony  more  marked  at  left  apex. 

Patient  reacted  to  tuberculin. 

Emphysema  not  suspected  by  Physical  Signs.  —  The  following  case 
is  illustrative  of  this  point :  — 

B.  O.,  thirty-two  years  old,  entered  my  service  at  the  hospital 
November   14,    1898.      Diagnosis  :    tuberculosis. 

November  23.    Many  tubercle  bacilli  found  in  sputum. 

X-ray  examination  ivitJi  screen  showed  an  increased  density  of  both 
lungs,  and  that  the  patient  was  suffering  from  emphysema  on  both  sides. 
This  latter  condition  was  not  indicated  by  the  physical  examination. 

b.  Tuberculosis  and  Bronchitis.  —  It  may  be  more  correct  to  say  that 
such  cases  are  cases  of  tuberculosis  that  have  been  mistaken  for  bron- 
chitis by  the  usual  methods  of  examination.  The  point  to  be  noted  is 
that  the  X-ray  examination  directs  our  attention  to  their  tuberculous 
character,  thus  rendering  the  physician  less  liable  to  mistake  a  bron- 
chitis for  a  pulmonary  tuberculosis.  The  following  case  illustrates  this 
point  :  — 

Eliza  T.,  fifty-six  years  old,  entered  my  service  at  the  hospital  Feb- 
ruary 18,   1897.     Father  died  at  ninety-eight;  mother  at  eighty -seven 


142     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

years  of  age.  Husband  died  of  tuberculosis.  The  patient  had  had 
cough  for  about  ten  months,  with  considerable  expectoration  ;  dyspnoea 
on  exertion,  and  weakness.  Physical  examination  of  lungs  showed  that 
both  chests  were  hyper-resonant  in  front  and  back  ;  chest  walls  thin  ; 
breathing  rather  harsh  ;  expiration  prolonged  ;  a  few  coarse  moist  rales 
in  back.      Diagnosis  :  bronchitis. 

February  25.  X-ray  examination  ivith  screen  showed  that  the  excur- 
sion of  the  diaphragm  was  5.25  centimetres  on  the  right  side  and  only 
3  centimetres  on  the  left  side.  This  Hmited  movement  suggested 
tuberculosis. 


Discharged. 

Eleven  months  later  the  patient  reentered  the  hospital  in  Dr.  George 
B.  Shattuck's  service. 

My  X-ray  examination  showed  that  the  whole  of  the  left  side  was 
less  clear  than  the  right,  and  that  the  apex  of  the  right  lung,  as  far  as 
the  second  rib,  was  less  clear  than  normal ;  that  there  was  hardly  any 
movement  of  the  diaphragm  on  the  left  side  ;  and  that  on  the  right  side 
the  excursion  was  only  3  centimetres. 

The  patient  had  had  several  small  haemoptyses.  Rather  indefinite 
physical  signs  at  both  apices.     Tubercle  bacilli  found. 

c.  Tuberculosis  and  Pleurisy  with  Effusion.  —  I  have  seen  some  cases 
of  pleurisy  with  effusion  ^  in  which  the  X-ray  examination  gave  evidence 
of  increased  density  at  the  apex  of  one  lung,  although  this  was  not  then 
detected  by  physical  signs.  The  testimony  of  the  fluorescent  screen 
was  confirmed  by  the  finding  of  tubercle  bacilli  or  by  the  tuberculin 
test. 

In  the  following  case  suspicions  of  tuberculosis  on  the  same  side  as 
the  effusion  were  suggested  to  me  by  the  X-ray  examination  :  — 

Gustav  L.,  forty  years  old,  entered  my  service  at  the  hospital  Feb- 
ruary 6,  1897.  Four  weeks  previously  had  had  a  chilly  sensation,  and 
seven  days  before,  pain  in  the  right  side  which  was  worse  on  respira- 
tion ;  some  expectoration. 

Physical  Examination.  —  Slight  dulness  at  the  right  apex  ;  somewhat 
diminished  breathing ;  vocal  and  tactile  fremitus  not  increased.  In  the 
right  back,  dulness  below  the  level  of  the  angle  of  the  scapula,  with 

1"  A  Study  of  the  Adaptation  of  the  X-Rays  to  Medical  Practice,"  Medical  and  Surgical 
Report  of  the  Boston  City  Hospital,  January,  1897. 


PULMONARY  TUBERCULOSIS  143 

diminished  breathing  and  voice  sounds.  Left  chest :  good  resonance 
and  respiration  over  all. 

March  13  and  19.     No  physical  signs. 

Second  and  TJiird  X-Ray  Examinations  ivitJi  Screen.  —  The  signs  of 
pleuritic  effusion  present  on  February  15  had  disappeared,  but  tubercu- 
losis was  indicated  by  diminished  clearness  of  the  whole  right  side,  the 
apex  was  darker  than  the  remaining  portion,  and  the  restricted  excursion 
of  the  diaphragm;  right  side,  2.5  centimetres;  left  side,  5.5  centimetres. 

Examination  of  the  sputa  showed  the  presence  of  tubercle  bacilli, 
which  confirmed  the  suspicions  aroused  by  the  X-ray  examination. 

I  have  recognized  by  means  of  X-ray  examinations,  tuberculosis  with 
emphysema  in  nine  cases ;  tuberculosis  with  bronchitis  in  eight  cases ; 
and  tuberculosis  with  pleurisy  in  thirteen  cases.  In  most,  though  in 
not  all,  of  these  thirty  cases  the  diagnosis  was  confirmed  by  finding  the 
tubercle  bacilli  or  by  the  tuberculin  test. 

Fourth.  Tuberculosis  indicated  by  Physical  Signs  but  not  by  X-Rays. 
—  The  foregoing  statements  and  illustrative  cases  testify  to  the  trust- 
worthy character  of  the  X-rays,  and  to  their  assistance  in  making  an 
early  diagnosis.  The  signs  afforded  by  the  X-rays  in  tuberculosis  are 
not  pathognomonic  of  this  disease.  Not  every  patient  with  these  signs 
is  suffering  from  phthisis,  nor  is  every  individual  with  a  good  movement 
of  the  diaphragm  and  clear  lungs  necessarily  free  from  tuberculosis ;  but 
if  we  find  clear  lungs  and  normal  outlines  in  an  otherwise  well  individual, 
we  have  an  excellent  assurance  that  pulmonary  tuberculosis  is  absent. 
The  X-rays  are  a  valuable  means  for  warning  us  of  this  disease  or  for 
indicating  that  we  should  reconsider  an  unfavorable  diagnosis. 

It  is  clear  that  caution  should  be  exercised  concerning  the  weight  to 
be  attached  to  negative  indications  by  the  X-rays  in  cases  where  there 
is  a  history  suggestive  of  tuberculosis,  or  some  physical  signs  indicating 
the  presence  of  this  disease.  I  hesitate  to  speak  of  this  class  of  cases, 
lest  the  mention  of  them  should  be  regarded  as  an  attempt  to  claim  too 
much  for  the  X-ray  examinations  in  diseases  of  the  lungs.  On  the 
other  hand,  I  think  it  would  be  unwise  to  pass  them  by,  as  they  repre- 
sent a  very  definite  line  of  experience  which  is  too  important  to  remain 
unnoticed.  In  some  cases  seen  by  me  the  symptoms  and  physical  signs 
indicated  pulmonary  tuberculosis,  but  the  X-ray  examinations  showed 
normal  lungs.  These  examinations  led  me  to  state  that  these  patients 
were  probably  not  suffering  from  this  disease ;  and  the  subsequent  his- 
tory or   the  tuberculin  test   indicated   that  this  interpretation  of  the 


144     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

appearances  seen  on  the  fluorescent  screen  was  correct.  While  the 
absence  of  tuberculosis  could  not  be  demonstrated  in  these  cases,  they 
do  show  that  the  X-rays  have  proved  of  value  in  aiding  me  to  decide 
what  the  patient  should  do.  That  is  to  say,  the  patients  have  been  able 
to  remain  at  home,  as  was  indicated  by  the  X-ray  examination,  instead 
of  seeking  another  climate,  as  was  suggested  by  the  suspicions  excited 
by  the  history  and  physical  examination.  The  importance  of  repeating 
the  X-ray  examination  at  frequent  intervals,  in  such  cases,  is  very  evi- 
dent. Likewise,  in  such  cases  reliance  should  be  placed  upon  X-ray 
examination  only  by  those  who  are  perfectly  familiar  with  the  disease 
in  all  its  forms,  as  well  as  with  the  use  of  the  X-rays. 

I  have  seen  several  cases  in  which  an  X-ray  examination  prevented  me 
from  taking  too  unfavorable  a  view,  though  the  physical  signs  had  indi- 
cated beginning  tuberculosis.  In  none  of  these  has  tuberculosis  de- 
veloped, and  in  such  of  them  as  I  could  test  with  tuberculin,  there  was 
no  reaction.     The  following  cases  are  illustrative  :  — 

Case  I.  David  G.,  thirty-nine  years  of  age,  entered  my  service  at 
the  hospital,  September  20,  1898. 

History.  — Old  pleurisy. 

Present  Illness.  —  Caught  cold  and  had  a  chill  and  knifelike  pains 
in  left  side. 

September  28.  Physical  Examination.  —  In  the  right  apex  in  front 
and  behind,  prolonged  expiration,  which  is  pitched  slightly  higher  on 
the  right  side ;  vocal  resonance  slightly  increased  ;  marked  whispered 
bronchophony  ;  in  the  right  base  behind,  numerous  medium  moist  rales 
heard  best  at  inspiration ;  no  change  in  percussion  and  voice  sounds ; 
two  negative  examinations  of  the  sputum. 

October  6.  Condition  had  improved  and  he  was  discharged  from 
the  hospital. 

October  18.  X-Ray  Examination  with  Screen.  —  Lungs  perfectly 
clear,  and  the  excursion  of  the  diaphragm  7  centimetres  on  both  sides. 

October  20.  Reentered  the  hospital.  Slight  dulness  in  the  right 
apex  in  front  and  behind,  with  some  increase  in  vocal  resonance  and 
fremitus,  and  considerable  whispered  bronchophony ;  no  rales  heard 
over  this  area  ;   lungs  otherwise  normal. 

November  4.  i  milligramme  of  tuberculin.  —  November  5,  5  milli- 
grammes of  tuberculin  ;  on  the  following  day  his  temperature  rose  to 
102.5  and  this  rise  was  attributed  to  the  tuberculin,  but  on  November  8 
his  temperature  rose  still  higher,  although  he  had  taken  no  tuberculin, 


PULMONARY   TUBERCULOSIS 


145 


namely,  to  105.5;  later  the  plasmodium  malariae  was  found  and  he 
was  given  quinine.  On  November  12  another  five  milHgrammes  of 
tuberculin  was  given,  but  there  was  no  reaction.  Examinations  of  the 
sputum  for  tubercle  bacilU  have  always  been  negative. 

November  16.  X-Ray  Examination  with  Screen.  —  Good  appearance 
of  the  lungs  on  both  sides ;  excursion  of  the  diaphragm  on  the  right  side 
7  centimetres  and  on  the  left  side  6.5  centimetres. 


J\fov  J6  —  Jiisa 
jVo  Jjqn  of'  TLiberciiioits 
on  Fjuorescenl'  -Dcreen 


J^ 


Fig.  91.  David  G.  November  i6,  1899.  X-ray  tracing.  (One-third  life  size.)  Good  appear- 
ance of  lungs  on  both  sides.  Excursion  of  diaphragm  on  right  side,  7  centimetres ;  on  left  side,  6.5 
centimetres. 

Physical  examination  on  the  same  day ;  Left  side  :  prolonged  and 
harsh  expiration,  and  tactile  fremitus  increased  as  far  as  the  third  rib  ; 
tactile  fremitus  also  increased  in  the  right  back,  and  a  slight  dulness 
over  the  whole  of  the  right  back. 

March  20.  X-Ray  Examination  zvitJi  Screen.  —  Patient  returned  to 
the  hospital  at  my  request  for  an  examination.  The  same  appearances 
were  found  by  the  X-rays  as  at  the  two  previous  examinations ;  that 
is,  on  October  i8  and  November  i6. 


146     THE   ROENTGEN   RAYS   IN   MEDICINE   AND   SURGERY 

When  this  patient  entered  the  hospital  he  was  thought  to  be  suffer- 
ing from  pleurisy,  and  perhaps  tuberculosis.  He  had  been  losing  in 
strength  and  weight,  and  his  friends  and  physician  deemed  it  desirable 
for  him  to  go  to  Colorado.  The  rise  in  temperature  directly  after  the 
administration  of  tuberculin  —  which  was  in  reality  due  to  malaria  — 
would  have  naturally,  if  the  plasmodium  malariae  had  not  been  found, 
been  considered  a  reaction  to  the  tuberculin.  The  diagnosis,  also 
naturally,  in  connection  with  the  other  signs,  would  have  been  tuber- 
culosis, and  the  X-rays  would  have  seemed  at  fault. 

October  30,  1899.  Another  X-ray  examination  zuith  screen,  at  my 
request:  lungs  clear;  excursion  of  diaphragm  7.5  centimetres  right 
side  and  8.7  centimetres  on  the  left  side. 

In  January,  1902,  when  I  last  heard  from  this  patient,  he  continued 
to  be  perfectly  well. 

Case  II.  James  G.  R.,  twenty-five  years  old,  entered  the  hospital 
August  23,  1898;  in  the  service  of  Dr.  Buckingham. 

History.  —  Well  and  strong  until  he  went  to  Cuba  ;  there  acquired 
a  dry  cough  and  lost  in  weight. 

August  23,  1898.  Physical  examination.  —  In  the  right  axilla  and 
right  base  behind,  as  far  up  as  the  level  of  the  angle  of  the  scapula,  are 
heard  numerous  moist  rales  and  an  occasional  whistle,  with  inspiration. 
No  increase  in  voice  sounds  over  this  area. 

September  i.  Second  Physical  exa^nination.  —  Marked  dulness  at 
the  apices  but  no  change  in  vocal  fremitus. 

September  6.  No  rales  heard  in  front  of  chest,  but  some  dry  and 
moist  ones  in  the  back.  Sputum  has  been  examined  a  number  of  times, 
but  no  tubercle  bacilli  found. 

October  6.     The   patient    gave  a  positive    reaction   to  Widal's  test. 

I  examined  this  patient  with  the  X-rays,  with  the  following 
result :  — 

October  31.  X-Ray  Exami?iation  ivith  Screen.  —  Lungs  clear  and 
normal  on  both  sides;  excursion  of  diaphragm  6.2  centimetres  on 
each  side. 

August  10,  1899.  I  met  this  patient  on  the  street,  and  he  was 
well,  and  had  been  well  since  he  left  the  hospital. 

Case  III.  M.  E.  F.,  October  6,  1898.  This  patient  was  sent  to 
me  by  her  physician  to  decide  whether  or  not  she  should  go  away. 

Present  Illness.  —  Loss  in  weight;  weighs  now  loi.]  pounds;  cough 
and    expectoration    for  three  or  four  weeks ;   still  some    cough  in  the 


PULMONARY   TUBERCULOSIS  147 

morning ;  dyspnoea  on  exertion  ;  pain  at  the  right  apex  and  increased 
vocal  fremitus.     Husband  died  of  tuberculosis  in  November,  1897. 

X-Ray  Exaviination  zvith  Screen.  —  Lungs  perfectly  clear ;  no  signs 
of  tuberculosis.     I  advised  waiting. 

December  30,  1898.  Second  X-Ray  Examination  xvitJi  Screen. — 
Lungs  still  perfectly  clear.  The  patient  had  gained  9]  pounds  in 
weight,  and  the  cough  had  stopped  a  month  before. 

June,  1900.  The  patient  came  to  me  again  for  an  examination, 
and  I  found  her  in  excellent  health. 

Fifth.  X-Ray  Examinations  of  Lungs  where  Tuberculosis  is  in  some 
other  portion  of  the  Body  than  these  Organs.  —  It  is  sometimes  of  great 
importance,  when  a  tuberculous  process  has  started  in  some  other  portion 
of  the  body  than  the  lungs,  to  learn  if  these  organs  have  also  become 
involved.  If  they  are  diseased,  it  might  be  necessary  that  the  patient 
should  change  his  career  ;  if  not,  there  seems  to  be  no  good  reason  why 
he  is  not  better  off  in  his  own  home,  doing  a  moderate  amount  of  work, 
but  taking  care  at  the  same  time  to  have  good  food,  sunshine,  and  fresh 
air  free  from  dust,  and  avoiding,  so  far  as  possible,  everything  detri- 
mental to  his  health.  The  assurance  which  X-ray  examinations,  made 
from  time  to  time  in  such  cases,  can  give,  that  the  lungs  are  not  in  an 
abnormal  condition  is  of  great  practical  value  and  a  source  of  relief  to 
both  the  patient  and  his  physician ;  and  I  beheve  that  if  we  find  the 
lungs  normal,  both  by  physical  and  X-ray  examination,  and  these  exami- 
nations are  made  at  suitable  intervals,  the  patient  runs  no  serious  risk 
in  staying  at  home,  and  it  is  not  necessary  to  advise  him  to  sacrifice  his 
business  and  the  other  plans  of  his  life  too  hastily. 

In  the  following  cases  and  in  the  case  mentioned  above  X-ray  exami- 
nations made  at  certain  intervals  are  of  value  :  — 

Sixth.  Precautionary  X-Ray  Examinations.  —  X-ray  examinations 
should  be  made  from  time  to  time  in  persons  from  fifteen  to  thirty 
years  of  age  if  the  family  history  is  tuberculous,  and  there  is  reason  to 
fear  that  the  given  individual  may  develop  tuberculosis.  In  this  way, 
if  the  disease  should  develop,  early  warning  would  be  given,  and  the 
best  opportunity  for  its  arrest  obtained. 

Relief  given  by  X-Ray  Examination.  —  Many  persons  dread  pulmo- 
nary tuberculosis,  or  fear  they  have  it  on  account  of  the  family  history, 
or  because  they  suffer  from  debility,  or  have  had  a  persistent  cough,  or 
other  symptoms  which   have  aroused  suspicion  in  the  minds  of  their 


1 48     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

physicians.  To  such  individuals,  the  assurance  which  careful  X-ray 
examination  can  give,  in  connection  with  other  signs  and  symptoms, 
that  the  lungs  are  normal  as  seen  by  the  fluorescent  screen,  is  a 
great  relief. 

Prognosis.  —  Whether  the  disease  is  progressing  or  improving  is 
often  indicated  by  comparing  successive  X-ray  examinations. 

B.     Old  Lesions  of  Tuberculosis 

Successive  X-Ray  Examinations.  —  Old  lesions  which  have  resulted 
from  tuberculous  conditions  long  healed  may  be  perceived,  and  the  pre- 
cautions which  their  existence  would  suggest  may  then  be  taken.  The 
physician  is  thus  enabled  to  guard  his  patient  against  the  dangers  of 
lighting  up  the  disease  afresh.  It  must  be  clearly  appreciated,  however, 
that  a  single  X-ray  examination  cannot  tell  us  whether  we  have  to  deal 
with  an  old  or  a  recent  pulmonary  tuberculosis,  —  whether  the  disease 
is  in  an  active  stage  or  not  is  to  be  learned  in  other  ways,  —  but  if  the 
disease  is  progressing,  successive  examinations  will  indicate  the  fact. 

The  following  case  shows  that  an  old  tubercular  lesion  gives  signs 
which  can  be  observed  by  an  X-ray  examination  :  — 

B.  C.  came  to  see  me  on  October  21,  1898,  and  was  interested  to 
learn  whether  or  not  an  X-ray  examination  would  disclose  any  evidence 
of  an  old  but  slight  lesion  which  he  had  had  in  November,  1892.  I  had 
no  history  other  than  the  above  ;  did  not  know  on  which  side  the  trouble 
had  been  during  the  attack  of  six  years  previous  ;  and  I  purposely  made 
no  examination  except  with  the  X-rays. 

October 2\,  1898.  X-Ray  ExaniinatioJi  with  Screoi. — Left  apex  was 
darker  than  the  right,  and  the  excursion  of  the  diaphragm  was  shorter 
on  the  left  than  on  the  right  side.  In  other  words,  the  X-ray  examina- 
tion indicated  that  the  trouble  had  been  at  the  left  apex. 

Through  the  kindness  of  B.  C.  and  Dr.  Trudeau,  I  give  a  copy  of 
the  records  made  at  the  Saranac  Sanitarium  by  the  latter  in  1892- 
1893:  - 

"  Twenty-nine  years  old,  family  history  non-tuberculous.  Personal 
history;  healthy,  but  not  vigorous  until  November,  1892.  Cough  and 
expectoration  ;  tubercle  bacilli  found.  All  symptoms  disappeared  by 
October,  1893  ;  none  since." 

"  Lesion  located  at  the  left  apex ;  pleuritic  friction  at  the  right 
base." 


PULMONARY   TUBERCULOSIS 


149 


At  my  suggestion  Dr.  Trudeau  kindly  made  a  physical  examination 
of  B.  C,  shortly  after  the  X-ray  examination,  that  is,  November  6,  1898. 
He  found  "slight  dulness  on  the  left  side,  appreciable  only  at  the  apex 
in  front ;  vocal  fremitus  about  the  same  on  both  sides.  Auscultation  : 
no  rales ;  vesicular  murmur  more  feeble  at  the  right  apex,  and  at  left 
apex  prolonged  and  slightly  broncho-vesicular ;  expansion  on  level  of 
nipple  hne  i^  centimetres  more  on  the  right  side  than  on  the  left. 
Should  not  consider  these  signs  by  themselves,  and  in  the  absence 
of  microscopical  evidence  or  constitutional  disturbance,  anything  more 
than  suggestive." 


'&&" 


C.     For  determining  Existing  Conditions  more  accurately 

More  Definite  Signs  by  X-Rays  than  by  Auscultation  and  Percus- 
sion. —  The  following  case  shows  that  the  X-ray  examinations  may  give 
unequivocal  signs  when  they  are  not  frankly  marked  by  auscultation 
and  percussion  :  — 

John  M.,  thirty  years  old,  entered  my  service  at  the  hospital  Febru- 
ary 21,  1899.      Diagnosis:  malaria. 

Family  histoiy,  negative.  Persona!  history :  fever  and  ague  four- 
teen years  ago  ;  about  seven  years  ago  had  a  bad  cough,  lasting  for 
some  months,  and  one  hemorrhage  in  which  he  lost  about  half  a  cup- 
ful of  blood ;  a  year  later,  another  hemorrhage  of  about  the  same 
amount ;  has  not  been  troubled  with  cough  since.  Present  illness  .-  chill 
and  fever  every  other  morning  for  two  weeks  ;  vomited  once ;  consider- 
able cough  and  expectoration  during  this  time ;  no  hemorrhage  ;  pain 
across  chest  when  he  coughs  ;  chill  this  morning. 

March  2.  X-Ray  Examination  ivith  Screen.  —  This  examination, 
made  on  the  same  day  as  above,  showed  that  the  right  apex,  to  the 
lower  border  of  the  third  rib,  was  darker  than  normal,  and  the  excursion 
of  the  diaphragm  was  shorter  and  higher  up  on  the  same  side,  5.]  centi- 
metres on  the  right  side  and  j\  centimetres  on  the  left  side ;  and  that 
the  heart  moved  more  to  the  right  than  normal  during  inspiration, 
because  the  left  lung  expanded  better  than  the  right.     (See  Fig.  92.) 

March  2.  Physical  examination,  made  after  X-ray  examination : 
Heart  area  normal,  action  regular,  no  murmurs.  Lungs  :  resonance 
good  over  all ;  slight  increase  of  vocal  fremitus  at  right  apex  front  and 
back,  perhaps  not  more  than  normal.  Expiration  prolonged  at  right 
apex  and  whispered  bronchophony  more  marked  than  normal. 


ISO    THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


The  diagnosis  of  tuberculosis  in  part  suggested  by  the  X-ray  exami- 
nation was  confirmed  by  the  tuberculin  test. 


John  M. 
Ala/ana 
Jiihercii/u3i5 


Fig.  92.     John  M.      X-ray  tracing.     (One-third  life  size.)     Right  apex  darker  than  normal; 
excursion  of  diaphragm  shorter  and  higher  on  right  side. 

Greater  Accuracy  of  X-Ray  Examination  confirmed  by  Autopsy.  — 

This  case  affords  confirmation  of  the  greater  accuracy  of  X-ray  exami- 
nations in  indicating  what  portions  of  the  pulmonary  areas  are  denser 
than  normal,  as  compared  with  auscultation  and  percussion. 

John  H.,  60  years  old,  entered  my  service  at  the  Boston  City  Hospi- 
tal on  December  30,  1899. 

Diagnosis  :   old  tuberculosis. 

One  careful  examination  for  tubercle  bacilli  was  negative. 

The  physical  signs  were  as  follows  :  Heart :  right  border  3  centi- 
metres to  right  of  median  line;  left  border  14.5  centimetres  to  left  of 
median  line  ;  upper  border  at  second  rib  ;  apex  in  fifth  space,  2.5  centi- 
metres outside ;  no  murmurs.  Lungs :  dulness  at  right  apex  in  front, 
down  to  third  interspace,  and  at  both  apices  behind.  Respiratory 
sounds  harsh.  Vocal  resonance  increased  at  both  apices.  Numerous 
medium  and  fine  crackling  rales  throughout  chest  at  times. 


PULMONARY   TUBERCULOSIS 


151 


January  3,  1900.  X-Ray  Examination  zvitk  Screen.  —  From  the 
physical  examination  I  supposed  that  we  should  find  the  apices  of  both 
lungs  to  be  the  parts  chiefly  affected,  but  the  X-ray  examination  showed 
that  the  apices  and  bases  of  both  lungs  were  less  involved  than  the 
other  portions. 

Jo/in  // 

Tiihfrca/oii3 


Fig.  93.  John  H.  January  3,  1900.  Tuberculosis.  X-ray  examination  with  screen  showed 
darkened  lungs,  but  apices  and  bases  less  affected  than  physical  signs  indicated.  Autopsy  confirmed 
X-ray  examination.  Excursion  of  diaphragm  shortened  on  both  sides.  See  Fig.  80  for  half-tone  of 
a  radiograph  of  lung.     (One-third  life  size.) 

The  patient  died  on  the  following  day,  and  the  post-mortem  exami- 
nation confirmed  the  X-ray  examination  and  proved  that  it  had  afforded 
a  better  picture  of  the  distribution  of  the  disease  than  had  auscultation 
and  percussion.  Dr.  Mallory  kindly  let  me  have  an  X-ray  photograph 
of  the  lungs  made  after  they  were  removed  from  the  chest,  and  I  have 
had  the  photograph  of  the  right  lung  reproduced  (see  Fig.  80);  to 
include  both  lunofs  would  have  reduced  the  scale  of  the  cut  too  much. 


D.     For  determining  the  Progress  of  the  Disease 

Acute   Tuberculosis.  —  In  acute  cases,  where  the   progress  of   the 
disease  is  rapid,  by  making  successive  X-ray  examinations  we  may  see 


152     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

the  extent  of  lung  area  involved  increase  almost  from  week  to  week, 
and  be  thus  warned  of  the  patient's  imminent  danger. 

Case  I.  Sarah  H.,  aged  twenty-three  years.  Entered  the  Boston 
City  Hospital  April  20,  1898,  and  was  placed  in  my  service.  She  had 
been  suffering  from  acute  articular  rheumatism,  first  in  the  right  ankle, 
then  in  the  left  ankle  and  elbow.  She  had  had  a  cough,  with  bloody 
expectoration,  for  two  weeks.  The  respiration  and  resonance  in  both 
lungs  were  good  throughout.  Heart  by  percussion  seemed  enlarged  to 
the  right. 

April  24.  X-Ray  Examination  ivith  Screen,  made  to  determijte  the 
Size  of  the  Heart.  —  This  showed  that  the  heart  was  not  enlarged  to 
the  right,  but  there  were  signs  of  tuberculosis  on  the  left  side,  namely. 


Jcirah  // 

Jpr//  24-^  1696  • 


Fig.  94.     Sarah  H.    April  24,  1898.    X-ray  tracing.     Left  apex  darker  than  normal.     Excursion   ot 
diaphragm  on  left  side,  5  centimetres;  on  right  side,  6.5  centimetres.     (One-third  life  size.) 


the  left  apex  was  shaded,  and  the  excursion  of  the  diaphragm  on  the 
left  side  was  5  centimetres,  while  on  the  right  side  the  apex  was  clear 
and  the  excursion  of  the  diaphragm  was  6.5  centimetres. 

April  29.     A  few  tubercle  bacilli  found  in  the  sputum. 

May  4.  Physical  Examination.  —  Slight  dulness  over  lower  left  back, 
where  many  crackling  rales  were  heard  at  the  end  of  full  inspiration. 
Right  apex  normal.  Also  dry  crackling  rales  over  left  front  and 
axilla. 


PULMONARY   TUBERCULOSIS 


153 


May  6.  X-Ray  Examiiiation  zuith  Screen.  —  Nearly  the  whole  of 
the  left  lung  was  shaded,  and  the  excursion  of  the  diaphragm  was 
shortened  by  1.25  centimetres  and  moved  3.7  centimetres  only.  The 
apex  of  the  right  lung  was  now  also  darker  than  normal,  and  the  excur- 
sion of  the  diaphragm  was  5.3  centimetres. 


V 


Fig.  95.  Sarah  H.  May  6,  1898.  Second  X-ray  tracing.  Increase  in  darkened  area  of  left 
lung  and  right  apex  also  shaded.  Excursion  of  diaphragm  on  left  side,  3.7  centimetres  (1.25  centi- 
metres shorter  than  on  April  24)  ;  on  right  side,  5.3  centimetres  (1.25  centimetres  shorter  on  this  side 
also  than  on  April  24).     (One-third  life  size.) 


May  12.  Physical  Examination.  —  Many  coarse,  moist,  and  fine 
dry  rales  over  left  back  and  axilla,  below  level  of  spine  of  scapula.  A 
few  fine  dry  rales  and  wheezy  expiration  over  lower  part  of  right  axilla. 
Over  this  area  resonance  is  diminished  slightly  and  tactile  fremitus  is 
increased. 

May  12.  X-Ray  Examination  with  Screen. — The  left  lung  was 
still  darker  than  it  had  been,  and  the  excursion  of  the  diaphragm  was 
reduced  to  2.5  centimetres.     Patient  up  and  about. 

May  12  and  14.  Sputum  examined,  but  no  tubercle  bacilli  were 
found. 


154    THE    ROENTGEN   RAYS   IN    MEDICINE    AND   SURGERY 


Jarcifi  Hi 

Fig.  96.    Sarah  H.     May  12.    Third  X-ray  tracing.     Left  lung  darker  than  on  May  6;  excursion  of 
diaphragm  reduced  to  2.5  centimetres  on  this  side.     (One-third  life  size.) 


Jara/i  H 


Maa 


IL 


Fig.  97.     Sarah  H.     May  17.     Fourth  X-ray  tracing.     Excursion  of  diaphragm  1.25  centimetres  on 
left  side ;  3.7  centimetres  on  right  side.     (One-third  life  size.) 


PULMONARY   TUBERCULOSIS  I  55 

May  17.  X-Ray  Examination  zvitJi  Screen.  —  The  excursion  of  the 
diaphragm  was  reduced  still  further,  namely,  to  1.2$  centimetres  on  the 
left  side,  and  to  'i,.']  centimetres  on  the  right  side. 

May  17.      A  few  tubercle  bacilli  were  again  found. 

Patient  died  in  July,  1898,  within  three  months  after  entrance. 

E.     In  determining  Extent  of  Disease 

In  making  successive  X-ray  examinations  of  patients  who  were  suf- 
fering from  tuberculosis  at  one  apex,  as  indicated  both  by  an  X-ray  and 
a  physical  examination,  in  order  to  watch  the  progress  of  the  disease, 
I  have  observed  that  as  the  process  went  on,  signs  were  evident  in  the 
other  apex,  by  an  X-ray  examination  before  there  were  physical  signs 
there.  Likewise,  I  have  seen  by  a  single  X-ray  examination,  when  the 
tuberculosis  was  well  advanced,  that  the  disease  was  more  extensive  than 
the  physical  examination  indicated.  This  information  aids  the  physician 
to  decide  whether  the  patient  should  go  away  or  remain  at  home,  and  to 
avoid  the  mistake  of  sending  him  away  when  he  is  beyond  a  reasonable 
hope  of  recovery,  and  of  thus  exposing  him  to  the  cruelties  of  a  forlorn 
and  expensive  journey,  and  separating  him  from  friends  as  well  as  home. 

The  following  case  is  illustrative  :  — 

Case  I.  L.  B.  C,  twenty-nine  years  old,  a  patient  of  one  of  my 
friends. 

History.  —  For  past  two  months  has  had  cough,  with  yellowish 
expectoration  ;  about  one  week  ago  sputum  was  streaked  with  blood  ; 
slight  dyspnoea  after  exertion  ;  no  sweating  ;  appetite  fair. 

May  II,  1898.  Physical  Examination.  —  Lungs  normal,  save  that 
the  breathing  was  somewhat  jerky  in  places,  and  the  fremitus  slightly 
increased  all  over  the  right  chest.  Rest  of  physical  examination  nor- 
mal.    Diagnosis  :  phthisis. 

May  13.  At  inner  edge  of  left  scapula  a  few  rales  ;  no  difference 
in  fremitus  or  voice. 

May  14.  An  occasional  indeterminate  rale  here  and  there  over 
chest,  not  permanent  in  character ;  no  abnormality  in  breathing  or 
voice  ;  resonance  good. 

May  15.  Breathing  very  little  qualitatively  modified.  As  before, 
there  are  occasional  rales,  and  in  right  axilla  after  cough  they  are  more 
numerous  than  elsewhere.      Tubercle  bacilli  found  i?i  sputum. 

I  examined  this  patient  with  the  X-rays,  with  the  following  result :  — 


156 


THE   ROENTGEN   RAYS   IN   MEDICINE   AND   SURGERY 


J/aj'  1 6.  X-Ray  Examination  with  Screen.  —  Right  side  dark  through- 
out; excursion  of  diaphragm  2.5  centimetres;  this  muscle  does  not 
descend  to  the  lower  portion  of  the  chest ;  on  left  side,  excursion  7 
centimetres  (Fig.  98). 


LBC 


Fig. 


L.  B.  C.     May  16,  1898.    X-ray  tracing.    Right  side  dark  throughout ;  excursion  of  diaphragm 
limited  on  this  side  to  25  centimetres.     (One-third  Hfe  size.) 


August  22.  Physical  Examination.  —  Moist  rales  present  in  both 
axillae ;  dulness  at  both  apices,  and  moist  bubbling  rales  ;  at  right  apex 
bronchial  breathing,  with  increased  resonance  and  fremitus. 

August  22.  Third  X-Ray  Examination.  —  Right  side  much  darker 
throughout  than  left;  excursion  of  diaphragm  .5  centimetre  on  right 
side  and  2  centimetres  on  left  side. 

At  this  time  the  patient's  plans  were  made  to  go  to  Denver,  and 
these  plans  were  carried  out ;  but  the  journey  was  strongly  contraindi- 
cated  to  my  mind  because  of  the  amount  of  disease  present,  and  the 
rapidity  with  which  it  had  increased,  as  shown  by  the  X-ray  examina- 
tions. He  remained  in  Colorado  a  few  days,  and  then  turned  his  face 
homeward,  dying  shortly  after  his  arrival  in  the  East. 


PULMONARY   TUBERCULOSIS  1 57 

F.     Acute  Miliary  Tuberculosis 

I  have  examined  with  the  X-rays  a  hing  taken  from  a  patient  who 
had  died  of  miliary  tuberculosis,  and  found  that  where  it  was  5  centi- 
metres thick  it  cast  a  shadow  on  the  screen  as  dark  as  that  made  by 
water  3  centimetres  deep,  held  in  an  aluminum  cup. 

Acute  miliary  tuberculosis  sometimes  offers  difficulties  in  diagnosis, 
and  is  confounded  with  some  other  disease,  typhoid  fever,  for  example. 
In  some  cases  there  may  be  no  physical  signs  by  auscultation  and  per- 
cussion, and  we  may  therefore  be  inclined  to  consider  that  pulmonary 
disease  is  absent ;  but  an  X-ray  examination  will  draw  attention  to  the 
fact  that  the  lungs  are  abnormal,  and  indeed  show  very  marked  signs, 
thus  directing  the  physician  to  a  correct  diagnosis. 

X-ray  examinations  may  also  render  service  when  the  process  is 
diffuse,  and  assist  us  to  determine  whether  the  disease  is  localized  or 
disseminated,  and  how  extensively  the  lung  or  lungs  are  involved. 

G.     Cavities  in  the  Lungs 

These  cavities,  when  filled  with  fluid  or  mucus,  would  appear  as 
dark  areas  on  the  screen  ;  when  filled  with  air  only,  as  light  areas  if 
the  surroundings  are  suitable.  That  is  to  say,  the  recognition  of  a  cavity 
depends  to  a  considerable  extent  upon  its  size,  as  compared  with  the 
thickness  of  the  encompassing  dense  lung.  Small  cavities  in  a  dense 
tuberculous  process  would  not  be  perceived. 

Case  L  G.  A.,  thirty-five  years  old,  entered  the  Boston  City  Hospi- 
tal October  14,  1896,  in  the  service  of  Dr.  A.  L.  Mason.  Diagnosis: 
tuberculosis. 

Good  resonance  in  right  chest  except  at  apex,  where  resonance  is 
lacking ;  breathing  rather  high-pitched  and  an  occasional  rale  after 
cough.  Left  lung:  resonance  high-pitched  at  apex,  becoming  markedly 
dull  below  on  front  and  back  ;  breathing  broncho-vesicular ;  increased 
tactile  and  vocal  fremitus  and  whispered  bronchophony  ;  numerous  fine, 
moist,  and  crepitant  rales  over  whole  chest.  Tubercle  bacilli  found.  At 
Dr.  Mason's  request  I  examined  this  patient  by  means  of  the  X-rays. 

X-Ray  Examination  zvith  Screen.  —  On  right  side,  from  apex  to  lower 
border  of  fifth  rib,  the  lung  is  darker  than  normal,  though  the  out- 
lines of  the  ribs  are  seen.  On  the  left  side  the  lung  is  dark  through- 
out, except  between  the  first  and  third  ribs,  where  there  is  a  light  area 


158     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

which  suggests  a  cavity.     The  left  border  of   the  heart  is  not   seen  ; 
the  diaphragm  on  the  left  side  is  barely  made  out. 

After  the  X-ray  examination  another  physical  examination  gave  the 
following  result :  left  apex,  percussion  rather  high-pitched  and  tympa- 
nitic in  quality  ;  breathing  amphoric. 

No  Signs  observed  by  X-Ray  Examination  in  Two  Cases  of  Tuberculo- 
sis.—  In  two  patients  who  undoubtedly  had  tuberculosis  I  found  no 
satisfactory  signs  by  X-ray  examination.  It  may  be  that  it  was  so 
distributed  as  to  be  difficult  of  recognition  by  X-ray  examination,  or 
that  my  experience  with  a  new  method  was  insufficient,  or  that  a  cer- 
tain proportion  of  cases  are  better  recognized  by  other  methods. 

Probability  tJiat  the  Shadoius  cast  upon  tJic  Fluorescent  Screen  in 
Pulmonary  Tuberculosis  are  due  in  Part  to  Congestion.  —  First,  an  experi- 
ment that  I  made  with  a  much  congested  lung  2\  centimetres  thick, 
taken  from  a  post-mortem  examination,  showed  that  this  lung,  which 
did  not  sink  in  water,  cast  a  shadow  corresponding  to  that  thrown  by 
water  nearly  2\  centimetres  deep. 

Second,  the  improvement  which  takes  place  in  some  cases  of  tuber- 
culosis, as  indicated  by  the  diminishing  shadow  cast  on  the  fluorescent 
screen  when  X-ray  examinations  are  made  at  intervals  of  a  week  or  so, 
could  hardly  be  due  to  any  improvement  in  the  tuberculous  process  — 
the  change  is  too  rapid  ;  but  it  might  easily  be  caused  by  a  diminution 
in  the  amount  of  congestion  in  that  portion  of  the  lung. 

In  passive  congestion  or  oedema  of  the  lungs  in  mitral  disease,  the 
lower  portions  of  these  organs  may  be  darker  than  normal  without  giv- 
ing signs  by  auscultation  and  percussion,  but  soon  become  clear  after 
rest  and  the  administration  of  digitalis.  Also  in  persons  suffering  from 
debility,  and  who  do  not  react  to  tuberculin,  we  may  find  a  dark  area 
in  the  lung  which  clears  up  after  a  rest  of  a  week  or  two. 

It  is,  of  course,  impossible  to  know  exactly  what  is  going  on  in  the 
lung,  and  to  distinguish  between  the  portion  of  the  shadow  cast  by  the 
increased  density  of  the  lung,  and  that  cast  by  an  increased  amount  of 
blood  in  the  lung,  due  to  local  congestion  ;  or  between  the  shadow  due 
to  a  tuberculous  process,  and  that  cast  by  a  process  which  may  be 
acute  in  character,  and  due  to  some  deposit  in  the  lung,  as  in  pneu- 
monia. The  history  and  symptoms  must  aid  us  in  this  last  dis- 
crimination. 

But  the  result  of  my  experience  thus  far,  with  a  considerable  num- 


PULMONARY   TUBERCULOSIS  159 

ber  of  cases,  shows  it  to  be  quite  possible  that  some  of  the  changes 
which  take  place  in  the  lungs,  as  seen  on  the  fluorescent  screen,  are  due 
to  the  temporary  presence  of  more  than  the  usual  amount  of  fluid  or 
some  semi-solid  substance,  which  can  be  absorbed. 

The  recognition  of  a  congestion,  especially  at  the  apex,  may  be 
valuable  in  some  cases  as  an  early  warning  of  a  beginning  tuberculosis, 
and  it  should  certainly  cause  us  to  make  a  careful  investigation  with 
this  diagnosis  in  mind.  In  those  cases  in  which  our  suspicions  are 
excited  by  a  first  examination,  or  in  doubtful  cases,  another  X-ray  exam- 
ination should  always  be  made  after  an  interval  of  some  days,  in  order 
that  the  second  examination  may  verify  or  disprove  the  first,  for  vari- 
ous conditions  may  temporarily  give  rise  to  signs  similar  to  those 
observed  in  pulmonary  tuberculosis. 

Therapeutic  Uses  of  the  X-Rays  in  Pulmonary  Tuberculosis.  —  The 
therapeutic  uses  of  the  X-rays  are  considered  in  another  chapter,  to 
which  the  reader  is  referred. 


Conclusion 

The  earlier  cases  cited  indicate  the  aid  the  X-rays  give  in  pulmonary 
tuberculosis  ;  the  service  which  they  may  render  in  the  early  diagnosis 
of  this  disease  stands  first,  and  perhaps  their  value  in  this  direction  will 
be  appreciated  more  strongly  if  the  following  statements  are  considered. 

First :  Pulmonary  tuberculosis  is  well  known  to  be  the  most  wide- 
spread of  all  diseases,  and  to  cause  the  death  of  more  persons  than  any 
other  malady -^one-seventh  to  one-eighth  of  all  deaths  are  due  to  this  dis- 
ease. In  Massachusetts  the  report  of  the  State  Board  of  Health  for 
1896  shows  that  643  out  of  looo  persons  dying  between  the  ages  of 
twenty  and  thirty,  died  of  tuberculosis,  and  597  out  of  lOOO  of  pulmonary 
tuberculosis.  Likewise  at  post-mortem  examinations,  signs  of  an  old 
and  healed  tuberculosis  are  recognized  in  many  cases  where  the  patients 
have  died  of  some  other  disease. 

Two  factors  are  of  importance  when  considering  the  development 
of  this  disease  :  first,  the  exposure  of  the  given  individual  to  the  tubercle 
bacillus,  and  second,  the  condition  of  the  individual  so  exposed ;  his 
powers  of  resistance  are  of  course  diminished  if  he  has  been  suffering 
from  disease  of  any  kind,  overwork,  or  bad  surroundings,  or  if  he  has  a 
predisposition  to  tuberculosis. 

Second  :  It  is  also  well  known  that  early  recognition  of  pulmonary 


l6o    THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

tuberculosis  is  of  the  first  importance,  as  then  food,  sunshine,  and  fresh 
air  can  frequently  arrest  it :  the  air  of  course  should  be  free  from  dust. 
A  striking  and  hopeful  illustration  of  the  importance  of  early  diagnosis 
in  disease  is  the  present  percentage  of  cures  in  diphtheria  as  compared 
with  the  past.  More  than  nine-tenths  of  the  patients  suffering  from 
diphtheria  now  recover  if  they  are  properly  treated  in  the  earliest  stages ; 
and  while  we  have  no  drug  like  antitoxin  with  which  to  treat  pulmonary 
tuberculosis,  yet  it  is  universally  recognized,  by  those  who  have  had  a 
large  experience,  that  even  in  our  cUmate  success  follows  suitable 
hygienic  and  dietetic  treatment  intelligently  and  persistently  carried  out, 
in  a  large  percentage  of  cases,  provided  this  disease  is  detected  in  its 
earliest  stages. 

Too  much  stress  cannot  be  laid  upon  the  importance  of  the  early 
recognition  of  an  abnormal  condition  of  the  lungs  when  there  is  a  ques- 
tion of  tuberculosis.  The  chances  of  recovery  are  far  greater  in  the 
early  stage  of  the  disease,  and  the  time  required  for  convalescence  is 
much  less  ;  nor  is  it  by  any  means  always  necessary  that  a  patient  should 
seek  another  climate.  The  fact  is  well  established  that  under  proper 
conditions  and  surroundings  tuberculosis  of  the  lungs  may  be  arrested 
by  a  natural  process,  if  taken  in  the  earliest  stages.  Not  only  do  post- 
mortem examinations  demonstrate  the  frequent  occurrence  of  healed 
tuberculous  areas  in  the  lungs,  but  direct  evidence  of  the  arrest  of  the 
disease  is  abundant  in  life.  The  best  time  for  successful  treatment  is  very 
early,  before  there  is  cough,  and  before  there  are  physical  signs  or  when 
these  are  not  definite.  To  keep  the  patient  under  observation  while 
suspicion  grows  into  apprehension,  and  apprehension  into  certainty, 
may  involve  a  fatal  result. 

It  will  be  said  that  comparatively  few  patients  can  afford  the  time 
or  the  money  necessary  for  a  cessation  from  work  and  for  a  change  of 
climate,  though  this  latter  point  is  not  always  required,  as  noted  above. 
The  length  of  time  demanded,  then,  to  arrest  the  disease,  is  an  impor- 
tant element  in  this  consideration  from  a  money  point  of  view.  Let  us 
suppose,  for  instance,  that  a  patient  in  whom  the  disease  has  progressed 
so  far  as  to  give  some  physical  signs  at  one  apex,  may,  under  suitable 
conditions,  recover  in  two  years ;  he,  like  most  others,  could  not  afford 
to  be  idle  for  so  long  a  time.  But,  on  the  other  hand,  if  the  diagnosis 
could  have  been  made  in  such  an  early  stage  of  the  disease  that  six 
months  would  have  sufficed,  the  problem  would  have  been  much  simpler  ; 
for  it  is  plain  that  the  number  of  those  who  could  afford  to  rest  six 


PULMONARY   TUBERCULOSIS  l6l 

months  would  far  exceed  those  who  could  give  up  two  years.  But  time 
and  money  are  not  the  only  or  the  chief  considerations.  This  "  money  " 
need,  which  often  covers  the  "  time  "  need,  can  in  some  cases  be  sup- 
plied by  friends,  but  no  friend  can  make  good  the  encroachments  of 
this  disease  if  it  is  too  far  advanced.  The  percentage  of  recoveries  from 
tuberculosis,  when  this  disease  is  in  such  an  early  stage  that  six  or  even 
four  months  is  sufficient  for  an  arrest  of  the  process,  will  be  much 
greater  than  in  the  class  of  cases  in  which  two  years  are  necessary ;  for 
this  added  length  of  time  means  that  the  disease  has  progressed  further. 

Let  us  return  to  the  money  point  of  view  again  for  a  moment.  It 
is  quite  conceivable  that  the  cost  of  maintaining  a  hospital  for  con- 
sumptives for  patients  who  are  comparatively  well  would  be  less  than 
that  where  the  inmates  needed  greater  care.  Moreover,  the  shorter  the 
time  necessary  for  the  patient  to  remain  in  the  sanitarium,  the  greater 
the  number  of  patients  who  could  be  cared  for  during  a  given  period. 
If  the  time  required  for  treatment  was  only  six  months,  twice  as  many 
patients  could  be  taken  care  of  than  if  a  year  were  necessary.  In  other 
words,  the  cost  of  maintenance  would  be  distributed  over  twice  as  many 
families  ;  and  if  the  shorter  time  only  were  necessary,  it  is  fair  to  suppose 
that  the  patients  or  their  friends  could  afford  to  pay  a  larger  proportion 
of  the  cost  of  maintaining  the  hospital.  Thus,  for  those  whose  means 
are  limited  the  hope  of  recovery  is  far  greater  by  a  very  early  diagnosis, 
not  only  so  far  as  the  disease  itself  is  concerned,  but  also  because  it 
brings  within  their  means  the  remedy  for  the  disease. 

Certain  of  my  patients  have  been  able  to  give  up  work  while  they 
were  still  comparatively  strong,  and  go  into  the  country  to  stay  with 
some  relative,  where  the  conditions  were  more  favorable  for  recovery 
than  in  their  old  environment,  and  they  have  done  well.  This  again 
shows  how  a  very  early  diagnosis  may  make  it  possible  for  the  family 
of  a  patient  to  assist  him  to  a  cure.  The  important  factor,  then,  in  the 
arrest  of  this  disease,  is  the  means  for  making  an  early  diagnosis ;  and 
I  think  it  will  be  admitted  by  all  those  who  have  had  a  large  experience 
in  making  examinations  of  the  chest,  that  any  method  which  yields 
signs  in  the  very  early  stage  of  tuberculosis  is  of  importance  and  deserv- 
ing of  careful  study. 

The  number  of  cases  of  early  tuberculosis  which  have  been  examined 
by  me  with  the  X-rays  is  naturally  not  very  large,  because  these  cases 
present  themselves  as  it  were  by  accident.  The  patients  who  come  to 
a  physician  for  an  examination  of  the  lungs  after  cough,  haemoptyses, 


1 62     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

or  other  symptoms  have  directed  their  attention  to  the  respiratory  system, 
would  in  the  nature  of  things  very  much  outnumber  those  who  came 
to  him  for  such  an  examination  when  there  were  as  yet  no  symptoms 
to  lead  them  to  suspect  their  lungs.  As  X-ray  examinations  come  into 
wider  use,  however,  and  —  hand  in  hand  with  this  point — when  general 
practitioners  learn  that  young  patients  who  are  anaemic,  who  have  lost 
flesh,  who  suffer  from  dyspepsia,  etc.,  are  in  a  suspicious  condition,  and 
should,  therefore,  have  their  lungs  carefully  examined,  the  number  of 
cases  in  which  the  diagnosis  is  made  at  an  early  and  useful  stage  will 
be  greatly  increased,  and  therefore,  also,  will  be  the  percentage  of 
recoveries.  In  other  words,  while  we  have  no  specific  remedy  for  tuber- 
culosis, an  early  diagnosis  and  proper  treatment  will  accomplish  the 
desired  end  in  the  majority  of  cases.  I  therefore  wish  to  emphasize  the 
significant  warning  given  in  these  general  symptoms  to  the  family  phy- 
sician—  which  may  anticipate  any  of  the  usual  signs  in  the  chest  —  and 
the  importance  of  making  as  careful  and  complete  an  X-ray  examina- 
tion of  the  lungs  as  possible  after  these  symptoms  have  been  noticed. 
With  the  use  of  the  X-rays,  in  connection  with  other  methods  of  exam- 
ination, tuberculosis  in  its  early  stage  will  be  less  frequently  overlooked 
than  formerly. 

The  importance  to  the  community  of  a  method  of  examination 
which  affords  timely  assistance  in  detecting  this  disease  is  obvious 
when  we  consider  the  prevalence  and  high  mortality  obtaining  in 
tuberculosis. 

After  twenty  years  of  practice  I  do  not  undervalue  any  of  the 
present  methods  of  examination,  nor  is  it  my  purpose  to  advocate 
giving  up  any  of  them  for  making  an  early  diagnosis  or  for  later  examina- 
tions—  we  need  all  the  available  aids  ;  but  I  do  strongly  urge  the  addi- 
tion to  them  of  careful  X-ray  examinations,  and  I  desire  to  emphasize  the 
value  of  this  method  in  affording  indications  of  pulmonary  tuberculosis 
in  the  earliest  stage  of  the  disease,  —  not  only  because  an  early  diag- 
nosis gives  the  best  opportunity  for  arresting  the  disease,  but  also  because 
patients  may  be  taught  simple  precautions  which  may  prevent  them 
from  becoming  a  source  of  contagion  to  others  should  cough  and  ex- 
pectoration develop.  We  have  had  two  methods  of  examining  the  heart 
and  lungs,  auscultation  and  percussion.  Each  of  these  in  suitable 
cases  gives  valuable  information  ;  they  require  a  trained  ear  and  expe- 
rience with  many  patients  to  make  them  serviceable.  In  some  cases 
auscultation  is  of  the  greater  value,  in  others  percussion.     More  fre- 


PULMONARY    TUBERCULOSIS  163 

quently  they  are  best  when  used  together.  To  these  we  may  now  add  a 
third  method,  that  of  X-ray  examination,  which  also  requires  special 
training. 

All  who  are  experienced  in  making  physical  examinations  of  the 
thorax  recognize  the  necessity  of  controUing  one  method  of  examination 
with  another.  Not  infrequently  we  understand  best  the  conditions  pres- 
ent, as  just  suggested,  by  taking  into  consideration  the  information 
obtained  from  inspection,  percussion,  and  auscultation  together,  and  if 
we  fail  to  do  this  we  may  err  in  our  diagnosis.  The  X-rays  give  another 
and  valuable  method  for  controlling  the  results  obtained  in  other  ways, 
and  also  add  to  them.  We  may,  by  their  use,  not  only  control  one 
method  by  another,  but  with  the  eye  supporting  the  ear  we  also  control 
one  sense  with  another. 


CHAPTER    VI 

PNEUMONIA 

The  abnormal  condition  of  the  lungs  in  pneumonia  is  shown  on  the 
fluorescent  screen,  not  only  by  the  obstruction  which  the  affected  parts 
offer  to  the  rays,  but  also  by  the  restriction  of  the  excursion  of  the 
diaphragm  on  the  lower  side.  The  first  point  is  demonstrated  by  the 
following  test,  which  I  made  in  1896:  — 

Through  the  kindness  of  Dr.  W.  T.  Councilman,  I  obtained  for  a  few 
moments  from  the  pathological  department  of  the  Boston  City  Hospital 
the  lungs  of  a  patient  who  had  died  of  pneumonia.  I  put  them  on  a 
photographic  plate,  enclosed  in  paper  which  had  been  shellacked  to  make 
it  waterproof,  and  then  made  an  X-ray  photograph  which  is  reproduced 
in  Figs.  99,  100.  The  dark  portions  represent  the  densest  parts  of  the 
lungs,  the  lightest  portions  the  normal.  It  will  be  seen  that  the  contrast 
between  the  two  is  very  marked.  By  further  experiment  I  found  that 
where  the  lung  was  most  dense,  and  5  centimetres  thick,  it  cast  a 
shadow  corresponding  to  that  made  by  water  about  5.5  centimetres 
deep,  and  that  such  portions  of  the  lung  sank  in  water.  Other  por- 
tions which  barely  floated  in  this  liquid  offered  the  same  resistance  to 
the  passage  of  the  rays  as  did  an  equal  depth  of  the  liquid,  both  when 
examined  under  the  fluorescent  screen  and  by  means  of  an  X-ray  pho- 
tograph. The  normal  part  of  the  lung  offered  very  little  obstruction 
to  the  passage  of  the  rays. 

Appearances  seen  in  Pneumonia  on  the  Fluorescent  Screen 

First :  Darkened  Lung.  —  The  foregoing  experiment  shows  that 
in  pneumonia  the  dense  lobes  cast  a  dark  shadow  on  the  fluorescent 
screen,  in  marked  contrast  to  the  light  areas  of  the  normal  portions 
of  the  lung.  The  absorption  of  the  rays  may  be  so  marked  as  to 
indicate  that  all  of  the  pulmonary  area  on  one  side,  and  much  of 
it    on    the    other,    is    nearly    or    quite    as    dense    as   the    liver.     When 

164 


PNEUMONIA 


165 


the  lung    has  increased  in    density  in  any  portion,  —  as  well  in  a  part 
near  the  middle  of  the  chest  as  near  the  surface,  —  it  will  cast  a  shadow 


Fig.  99.  Lung  of  a  patient  who  died  of  pneumonia.  The  lightest  portion  is  healthy ,  the  dark- 
est parts  have  been  more  affected  bv  the  pneumonic  process  than  those  that  are  less  daik.  It  is 
noteworthy  that  the  smaller  bronchi  show  as  light  lines  m  the  dark  portions  of  the  lungs.  1  his  lung 
was  taken  on  the  same  plate  with  that  shown  in  the  next  figure. 

on  the  fluorescent  screen.     In  this  fact  hes  one  of  the  advantages  of  an 
X-ray  examination  over  percussion;  for  while  by  the  latter  method  we 


1 66     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

detect  modifications  in  density  in  portions  not  far  from  the  chest  wall, 
we  may  fail  to  get  a  change  in  the  percussion   note  when  the  denser 


'% 


0' 


Fk;.  ioo.  The  other  lung  ol  a  patient  who  died  of  pneumonia.  The  lightest  portion  is  healthy; 
the  darkest  parts  have  been  more  affected  than  those  that  are  less  dark.  This  lung  was  taken  on  the 
same  plate  with  that  shown  in  the  preceding  figure. 

portions  of  the  lungs  are  more  remote.  If  the  density  is  much  below 
the  surface,  as  in  central  pneumonia,  its  presence  is  not  recognized 
by  physical  examination  ;  a  shadow,  however,  of  the  consolidated  portion 


PNEUMONIA  167 

of  the  lung  is  cast  on  the  fluorescent  screen  just  as  surely  as  if  the 
pneumonic  process  were  near  the  surface,  as  suggested  above.  My 
X-ray  examinations  have  demonstrated  the  presence  of  such  dense 
central  portions  or  central  pneumonias,  and  have  also  shown  that  in 
cases  of  convalescence  from  pneumonia  we  may  see  the  shadow  of  the 
dense  parts  of  the  lungs  which  are  distant  from  the  surface  when  they 
are  not  recognized  by  auscultation  and  percussion.  These  observations 
and  others  noted  on  page  158,  Chapter  V,  show  why  we  may  detect 
increase  in  density  with  the  X-rays  in  cases  where  it  is  not  found  by 
auscultation  and  percussion,  and  that  under  some  conditions  the  X-rays 
are  the  more  delicate  test. 

Second :  Diaphragm  Lines.  —  The  excursion  of  the  diaphragm  is 
shortened  in  pneumonia,  and  shortened  as  a  rule  on  its  lower  side,  on 
one  or  both  sides  of  the  chest,  owing  to  the  failure  of  the  lung  or  lungs, 
as  the  case  may  be,  to  expand  to  their  normal  extent  because  of  their 
increased  density,  and  also  perhaps  because  of  pleuritic  adhesions.  In 
some  cases  the  diaphragm  lines  are  a  more  delicate  test  than  the  shadow 
cast  on  the  screen  by  the  dense  portion  of  the  lung.  If  the  pneumonic 
process  is  extensive  the  diaphragm  lines  may  be  altogether  obliterated 
on  one  or  both  sides  of  the  chest. 

Third :  Displacement  and  Enlargement  of  the  Heart.  —  If  the  dis- 
tribution of  the  pneumonia  is  such  that  the  outline  of  the  heart  can  be 
followed,  this  organ  is  seen  to  be  enlarged,  especially  on  the  right  side, 
and  in  some  cases  a  much  enlarged  right  auricle  can  be  made  out. 
Where  the  pneumonia  is  on  one  side  only,  there  is  apt  to  be  some  dis- 
placement. If  the  lower  portion  of  the  left  lung  is  involved,  the  right 
border  of  the  heart  may  be  seen  on  the  screen  farther  to  the  right  than 
in  health  :  partly  because  the  heart  is  enlarged,  as  it  is  frequently  seen 
to  be  in  pneumonia  ;  and  partly  because  the  dense  lung  pushes  the 
heart  a  little  to  the  right.  Where  the  process  in  the  lung  is  so  distrib- 
uted that  the  size  of  the  heart  may  be  observed  by  means  of  the  X-rays 
through  the  active  stages  of  the  disease,  it  becomes  evident  that  the 
size  and  position  change,  the  enlargement  lessening,  and  the  heart 
approaching  nearer  and  nearer  to  the  normal  in  position  and  size  as  the 
lung  improves. 

Usual  Region  affected.  —  The  middle  portion  of  the  lung,  that  is  to 
say,  the  part  between  the  second  and  fourth  ribs,  is  the  region  most 
frequently  affected  when  the  pneumonic  process  is  not  extensive.  We 
often  find  the  apex  and  the  base  comparatively  free  from  disease.     The 


1 68     THE    ROENTGEN    RAYS   IN    MEDICINE    AND   SURGERY 

following  diagram  indicates  the  appearances  frequently  met  with  when 
only  a  small  part  of  the  lung  is  involved  ;  it  is  made  from  the  examina- 
tion of  a  patient  with  the  fluorescent  screen  on  the  seventeenth- day  of 
the  disease  :  — 


Fig.  lor.     Diagram  of  pneumonia.     Seventeenth  day  of  disease.     No  physical  signs  on  or  after 

this  day. 
Dark  area  and  restricted  movement  of  the  diaphragm  on  the  left  side;    the  movement  is  also  less 
than  normal  on  the  right  side.     The  dark  area  diminished  gradually,  and  the  excursion  of  the  dia- 
phragm on  both  sides  increased  from  week  to  week.    There  were  still  X-ray  signs  on  thirty-second  day. 

Method  of  Examination. — The  methods  of  examination  for  this 
disease  are  sufficiently  indicated  in  the  general  directions  given  in 
Chapter  III,  and  the  special  ones  in  Chapters  V  and  X  and  by  the 
following  cases  and  cuts,  and  need  not  be  further  discussed. 


PNEUMONIA 


169 


Comparative  Value  of  the  Fluorescent  Screen  and  X-Ray  Photograph 
in  Pneumonia.  —  It  seemed  to  me  important  to  compare  the  two 
methods  of  X-ray  examination  in  pneumonia,  and  the  result  demon- 
strated the  superiority  of  the  screen  over  the  photograph  in  this 
disease.  I  will  give  an  outline  of  one  of  the  cases  in  which  a  compari- 
son was  made,  in  order  to  show  how  the  experiment  was  carried  out. 

Case  I.  Christine  P.,  aged  six  years;  pneumonia;  entered  my  ser- 
vice at  the  hospital  on  the  third  day  of  the  disease.  The  physical 
signs  were  not  well  marked,  but  the  X-ray  examination  made  on  the 
following    day  indicated  a  dense    area   7    centimetres  wide,  extending 


C hri3llne  P 
Pneumonia 

More  ft  JZ-s^ 


Fig.  102.  Lihristine  P.  Pneumonia  on  left  side  in  girl  six  years  old.  X-ray  tracing  made 
on  the  sixteenth  day  of  disease.  There  were  no  signs  by  auscultation  and  percussion,  though  as 
shown  by  the  above  copy  of  the  X-ray  tracing,  the  signs  by  the  fluorescent  screen  were  still  well 
marked.  X-ray  photograph  showed  no  increase  of  density  in  the  lungs,  but  a  slight  increase  is  seen 
m  the  reduced  picture  shown  on  page  170  (see  Fig.  103).     (Cut  one-third  life  size.) 


outward  and  upward  from  the  left  border  of  the  heart.  The  excursion 
of  the  diaphragm  on  the  left  side  was  0.6  centimetres  ;  on  the  right  side 
2.5  centimetres.  On  the  sixteenth  day  of  the  disease  the  darkened  area 
had  grown  much  lighter,  but  was  still  readily  perceived,  and  the  excur- 
sion of  the  diaphragm  was  2.5  centimetres  on  the  left  side,  and  4.7 
centimetres  on  the  right  side.     (See  Fig.  102.) 

As  at  this  date  there  were  no  physical  signs  in  the  lungs  of  this 
patient,  nor  had  been  for  four  days,  although  the  signs  of  departure 
from  the  normal  were  very  patent  on  the  fluorescent  screen,  the  case 
seemed  to  me  a  favorable  one  in  which  to  make  the  comparison  between 


lyo 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


the  value  of  the  X-ray  photograph  and  the  screen  in  this  disease. 
Three  photographs  of  the  chest  were  taken,  one  on  March  30,  and  two 
on  March  31,  to  see  if  variation  in  the  time  of  exposure,  or  tubes  of 
different  resistance  would  bring  out  anything.  Several  prints  were  made 
from  each  of  these  negatives,  and  in  none  of  them  did  I  find  evidence 
of  increased  density  in  the  left  lung  as  compared  with  the  right.  There 
were  no  indications  of  the  presence  of  pneumonia  by  means  of  the 
X-ray  photograph,  although  the  signs  on  the  screen  at  this  time,  as  just 
stated,  were  obvious,  the  darkened  area  and  the  restricted  excursion 
of  the  diaphragm  being  visible.  This  latter  condition  was  probably  due 
in  part  to  pleuritic  adhesions  limiting  the  movement  of  the  lung. 

After  the  above    paragraphs  were  written   the  following   half-tone 
was  made  from  one  of  the  radiographs.     The   half-tone  (see  Fig.  103) 


Fig.  103.     Christine  P.     Cut  from  radiograph  which  was  made  on  the  same  day  that  the  radioscopic 
tracing  was  drawn.    X-ray  tracing  (see  Fig.  102)  shows  well-marked  signs. 


PNEUMONIA 


171 


shows  a  slight  increase  in  density  on  the  left  side  which  was  not  visible 
in  the  radiographs  themselves.  This  slight  density  seems  to  have  been 
made  evident  by  the  reduction  in  size  of  the  X-ray  photograph. 

The  following  case  shows  the  appearances  seen  in  pneumonia,  namely, 
the  limitation  of  the  movement  of  the  diaphragm  on  the  affected  side, 
and  the  darkened  lung ;  likewise  the  difference  between  the  signs 
observed  by  X-ray  examination,  and  by  auscultation  and  percussion  :  — 

Case  I.  Edward  R.,  twenty-five  years  old,  entered  my  service  at 
the  Boston  City  Hospital,  March  ii,  1898.     Diagnosis:  pneumonia. 

Family  History. — Negative. 

Present  Illness.  —  For  three  days,  cough  ;  pain  in  right  side  ;  vomit- 
ing.    Had  been  drinking  heavily. 


Hckaarc/  /? 
CenJrrJ  Pneumanja    Fli^h/Jic/e  ^jjperPor/ron 


Fig.  104.  Edward  R.  March  12.  Cut  of  X-ray  tracing.  Central  pneumonia  ;  right  side  ;  upper 
portion.  Heart  enlarged  to  the  right.  Physical  signs  indicated  that  disease  was  present  in  the  lower 
part  of  right  chest.     X-ray  e.xamination  confirmed  by  autopsy.     (One-third  life  size.) 


Physical  Examination.  —  Heart :  right  border  2  centimetres  to  right 
of  sternal  border  ;  left  border  in  nipple  line  ;  apex  beat  in  fifth  space  in 
nipple  line  ;  no  murmurs.  Lungs :  resonance  good  throughout ;  respi- 
ration over  right  lung,  bcloiv  third  rib  in  front  and  spine  of  scapula 
behind,  harsh. 

Temperature  103  to  104;  pulse  120  to  130;   respirations  32  to  36. 


172     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

March  1 2.  X-Ray  Examination  xvitJi  Screen.  —  The  tracing  (see  Fig. 
104)  made  on  the  chest  of  this  patient  showed  that  the  upper  pa7-t  of 
the  right  king  was  very  dense,  and  below  that  point  it  was  much  hghter. 
The  excursion  of  the  diaphragm  was  much  shortened  on  that  side. 

Developed  dehrium  tremens  and  died  on  March  14. 

March  16.     Autopsy  showed  the  upper  lobe  of  the  right  lung  com- 


FQ 

Pneumonia 


Fig.  105.  F.  G.  Pneumonia  on  both  sides.  Cut  of  X-ray  tracing.  Signs  more  marked  on  left 
side  by  X-rays  than  by  auscultation  and  percussion  ;  more  marked  on  both  sides  by  fluorescent  screen 
than  by  X-ray  photograph.     (One-third  life  size.) 


pletely  distended  and  solidified  throughout ;  middle  and  lower  lobe 
slightly  increased  in  density. 

This  patient  entered  the  hospital  on  the  fourth  day  of  the  disease. 
The  physical  signs  indicated  that  pneumonia  was  present  in  the  lozver 
part  of  the  right  chest,  below  the  second  rib  in  front  and  the  spine  of 
scapula  behind.  The  only  indication  given  by  physical  signs,  however, 
was  the  harsh  breathing.     The  resonance  was  good  throughout. 

The  physical  examination  was  made  on  March  11,  the  X-ray  exami- 


PNEUMONIA  173 

nation  on  March  12,  and  the  patient  died  on  March  14.  It  is  instruc- 
tive to  compare  the  conditions  found  by  the  physical  examination  with 
those  found  by  X-ray  examination  and  at  the  autopsy.  It  is  evident 
from  these  latter  that  the  disease  had  been  chiefly  present  in  the  upper 
lobe,  which  was  completely  solidified  throughout.     (See  Fig.  104.) 

Comparison  of  X-Ray  with  Physical  Signs,  and  of  Screen  with  X-Ray 
Photograph.  —  F.  G.,  forty  years  old,  entered  my  service  at  the  hospital 
January  4,  1900.      Diagnosis:  pneumonia  on  both  sides.     (Fig.  105.) 

The  interesting  points  in  this  case  were,  first,  that  the  signs  observed 
on  the  left  side  by  the  X-rays  were  more  marked  than  those  obtained 
by  auscultation  and  percussion  ;  second,  the  appearances  seen  on  both 
sides  were  more  marked  on  the  screen  than  on  the  X-ray  photograph. 

Extent  of  Disease.  —  The  X-rays  show  the  extent  of  the  disease  ; 
whether  or  not  it  is  limited  to  one  lobe,  or  includes  the  whole  of  one 
lung  and  part  of  another. 

Outline  of  Pneumonia  sharply  defined.  —  The  outline  between  the 
normal  and  abnormal  portion  of  the  lung  may  be  sharply  defined  on  the 
fluorescent  screen.  The  following  case  illustrates  the  sharp  definition 
of  the  dense  areas  that  sometimes  obtains,  as  well  as  the  significance  of 
the  diaphragm  lines  and  the  limitation  of  the  disease  to  one  lung  :  — 

Case  I.  Bernard  McL.,  nineteen  years  old,  entered  my  service  at 
the  hospital  February  11,  1897.      Diagnosis:  pneumonia. 

Physical  Examination.  —  Marked  dulness  over  upper  right  chest 
down  to  fourth  rib ;  breathing  intensely  bronchial  with  a  few  moist  rales 
and  increased  vocal  and  tactile  fremitus ;  dulness  in  right  axilla  with 
harsh  breathing.  In  right  back,  dulness  from  apex  to  level  of  middle 
of  scapula ;  breathing  broncho-vesicular ;  many  fine  moist  rales.  In 
left  chest,  front,  and  back,  there  is  good  resonance ;  many  fine  and 
coarse  moist  rales  at  base  and  back. 

February  13.  X-ray  examination  %vith  screen  on  seventh  day  of  dis- 
ease ;  right  lung  dark  from  middle  of  first  intercostal  space  to  fourth 
rib,  the  upper  and  lower  border  of  this  dark  area  well  marked.  Out- 
lines in  chest  rather  less  clear  than  normal  on  both  sides.  Diaphragm 
moved  0.6  centimetres  on  the  right  side  and  4  centimetres  on  left  side. 

It  will  be  seen  that  the  Hmits  of  the  dense  lung  were  well  defined 
both  above  and  below  (Fig.  106).  The  physical  examination  did  not 
show  that  the  lung  was  clear  at  the  extreme  apex. 

X-Ray  Examination  zvith  Screen.  —  Fifteenth  day  of  disease  ;  dia- 
phragm moved  2.5  centimetres  on  the  right  side,  6.25  centimetres  on 


174 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


the  left  side.  Twentieth  day  of  disease;  diaphragm  moved  5  centi- 
metres on  right  side,  7  centimetres  on  left  side ;  original  dark  area 
has  grown  steadily  lighter,  but  is  not  yet  so  bright  as  other  portions  of 


A^ame 
/ddress 


Occupation 


Vol  ^/ 7  Page   ZZZ 


Fic.  106.  Bernnrd  McL.  Pneumonia.  X-ray  examination  with  screen  ;  seventh  day  of  disease. 
Outline  of  pneumonia  sharply  defined.  Lung  clear  at  apex.  Physical  examination  did  not  show 
this  fact.  Movement  of  diaphragm  on  right  side,  0.6  centimetres;  on  left  side,  4  centimetres.  (One- 
third  life  size.) 

the  lung.      Tivcnty-second  day  of  disease;  diaphragm  moved  6.25  centi- 
metres on  the  right  side  and  7.5  centimetres  on  the  left  side. 

Persistence  of  X-Ray  Signs.  —  Improveniejtt  watcJied  on  the  Flnores- 
cent  Screen.  However  much  the  lungs  may  be  affected  in  pneumonia, 
we  may  see  by  means  of  successive  X-ray  examinations  with  the  fluores- 


PNEUMONIA 


175 


cent  screen  that,  as  the  patient  begins  to  improve,  the  dark  areas  seen 
on  the  screen  become  Ughter  and  lighter,  and  diminish  in  extent,  until 
they  finally  disappear.  We  may  also  watch  the  diaphragm  and  see  that 
its  excursion,  which  has  been  restricted,  and  restricted  on  the  lower  side, 
gains  in  length  as  the  lungs  clear  up.  The  following  case  is  given  to 
illustrate  these  points,  and  also  to  show  that  the  results  of  the  pneu- 
monic process  may  be  followed  on  the  fluorescent  screen  when  there 
are  no  longer  signs  by  auscultation  and  percussion.  The  position  of 
the  heart  is  only  referred  to  briefly. 

The  X-ray  examinations  in  this  case,  seven  in  all,  were  made  on  the 
following  dates,  namely,  March  7,  13,  19,  and  24;  April  i,  8,  and  12; 
but  I  only  give  reproductions  of  the  tracings  made  on  March  7,  13,  24, 
and  April  8.  It  will  be  seen  by  examining  them  that  as  the  lungs 
cleared  up  the  excursion  of  the  diaphragm  increased  in  length.  On 
March  7  this  muscle  had  but  a  short  excursion  on  the  left  side,  and 
could  not  be  seen  on  the  right  side.  On  March  13  the  diaphragm  could 
be  seen  on  both  sides,  and  moved  about  1.25  centimetres  on  each  side. 
On  March  24  it  moved  2.2  centimetres  on  the  right  side,  and  3.4  centi- 
metres on  the  left  side;  April  8,  3.4  centimetres  on  right  side,  4  centi- 
metres on  left  side.  It  will  also  be  seen  in  the  notes  of  the  case  that  there 
were  no  physical  signs  on  April  i,  or  subsequently,  although  signs  of  an 
abnormal  condition  of  the  lungs  could  be  seen  on  the  fluorescent  screen 
on  April  6,  8,  and  12.     The  details  of  this  case  are  given  at  some  length. 

Case  I.  G.  R.,  thirty-three  years  old,  entered  my  service  at  the 
hospital  February  21,  1897.      Diagnosis:  pneumonia. 

Nine  days  before  entrance  patient  had  chill,  fever,  and  sweating  ; 
severe  headache ;  pain  in  right  chest ;  dyspnoea ;  cough  with  rusty 
expectoration. 

Physical  Examination.  —  Tympany  over  upper  right  chest,  with  loud 
harsh  breathing  and  moist  rales ;  below  fourth  rib  in  right  front  dulness 
on  percussion  extending  into  axilla ;  breathing  diminished ;  increased 
vocal  and  tactile  fremitus.  In  right  back  dulness  begins  at  spine  of 
scapula,  flatness  from  angle  of  scapula  to  base ;  breathing  over  this  area 
intensely  bronchial  in  character  with  great  increase  in  whispered  and 
spoken  voice  sounds;  many  fine  moist  rales  at  end  of  inspiration. 
Some  dulness  in  lower  left  back  with  increased  voice  sounds  ;  many  fine 
and  coarse  moist  rales  ;  breathing  bronchial  but  not  so  intense  as  on  right 
side  ;  breathing  harsh  at  left  apex.  Good  resonance  over  left  chest  in 
front,  with  harsh  noisy  breathing  and  loud  coarse  rales. 


176     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

February  24.  Physical  Examination.  —  Whole  of  right  chest  perfectly 
flat  on  percussion  ;  breathing  amphoric,  with  fine  moist  rales ;  breathing 
rather  diminished  in  axilla,  and  of  bronchial  character.  Whole  of  right 
back  flat  on  percussion  ;  breathing  intensely  bronchial,  with  increased 


Name 
Address 


Ocaipalion  Vol.  Po,ge 


Viagnosis 


Fig.  107.  G.  R.  I- irst  X-rav  examination  with  screen.  Pneumonia  on  both  sides.  Diaphragm 
not  seen  on  right  side  as  the  lung  is  too  dense;  excursion  on  left  side  2.5  centimetres.  (One-third 
life  size.) 

voice  sounds  and  tactile  fremitus  ;  many  fine  moist  rales  over  whole  back. 
Signs  in  left  chest  as  at  first  examination. 

February  26.     Temperature  fell  by  crisis  from  103  to  normal. 

March  7.  Physical  Examination.  —  Right  chest  in  front,  percussion 
rather  higher  pitched  than  on  the  left ;  vocal  fremitus  increased  ;  many 


PNEUMONIA 


177 


rales;  in  right  back,  percussion  duller  than  in  left  back,  and  vocal 
fremitus  increased.  Left  chest :  in  front,  harsh  breathing  over  most  of 
the  left  side ;  in  back,  breathing  better  than  in  right  back ;  vocal 
fremitus  increased. 


Name 

Address 

Diagnosis 


6.^ 


\- 


Age 

Occupation 


Date 


'OAc/  /^ 


Vol. 


Page 


Fig.  108.  G.  R.  Second  X-ray  examination  with  screen.  Patient  improving.  Excursion  of  dia- 
phragm 1.25  centimetres  on  right  side;  increased  on  left  side.     (One-third  life  size.) 

MarcJi  7.  X-Ray  Examination  with  Screc7i,  as  shown  in  cut  of 
tracing  made  on  this  day  (see  Fig.  107).  —  The  whole  of  the  right  chest 
was  dark  ;  no  outlines  seen  ;  the  lower  portion  of  the  right  chest  rather 
lighter  than  the  upper  portion,  which  indicated  consolidation  of  the 
lung   and   not  pleurisy  with  effusion.     The  heart  was  not  displaced  to 


178     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 


the  left.  On  the  left  side  the  upper  three-fourths  of  the  left  chest 
was  less  clear  than  normal  ;  some  movement  of  the  diaphragm  could 
be  followed. 

March  13.     X-Ray  Examination  with  Screen.  —  The  chest  was  much 
clearer  on  both  sides  than  on  March  7.    The  ribs  were  very  faintly  visible 


Name 

Address 

Diagnosis 


^./?. 


Age 
Occupation 


Date 


Page 


Vot. 


I'lG.  109.     Ci.  k.     Third  X-ray  examination  with  screen.     StiU  further  improvement.     Excursion 
of  diaphragm  on  right  side,  2  centimetres  ;  on  left  side,  3.5  centimetres.     (One-tliird  life  size.) 

on  the  right  side,  and  a  shortened  excursion  of  the  diaphragm  could  be 
barely  made  out.  On  the  left  side,  from  the  second  to  the  fourth  ribs, 
inclusive,  the  chest  was  darker  than  normal.  Below  the  fourth  rib  on 
this  side  was  the  lightest  part  of  the  thorax.  Excursion  of  the  dia^ 
phragm  1.25  centimetres.     (See  Fig.  108.) 


I 


PNEUMONIA 


179 


On  March  19,  X-ray  examination  ivitk  screen  (of  which  no  tracing 
is  reproduced)  showed  the  whole  of  the  right  side  darker  than  the  left. 
The  diaphragm  on  this  side  was  the  width  of  a  rib  higher  than  on  the 
left  side  and  had  an  excursion  of  1.25  centimetres.  On  the  left  side  the 
excursion  of  the  diaphragm  was  3  centimetres. 


Name 


^K. 


Address 

Dtacwsis 


Age 

Occupation 


JDate 


Jft'.iiZ 


Vol. 


""V- 


Fig.  iio.    G.  R.     Fourth  X-ray  examination  with  screen.     Signs  by  X-rays;  shaded  lungs  and 
jxcursion  of  diaphragm  restricted  on  both  sides.    No  physical  signs  at  this  time.    (One-third  hfe  size.) 

! 

i       MarcJi  24.     Physical  Examination.  —  Slight  increase  in  dulness  on 
i:he  right  side  ;  respiratory  murmur  shorter  than  on  the  left  side. 
I       March  24.   X-Ray  Exixmination  with  Screen.  —  Dark  area  on  the  upper 
[portion  of  the  right  side,  as  far  down  as  the  third  rib.     Dark  area  about 


l8o     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

over  the  third  rib  on  the  left  side.  Excursion  of  the  diaphragm  on  the 
right  side,  from  about  the  upper  border  of  the  fourth  to  the  upper  border 
of  the  fifth  rib,  2  centimetres ;  on  the  left  side,  from  the  middle  of 
the  fourth  intercostal  space  to  the  lower  portion  of  the  fifth  intercostal 
space,  3.5  centimetres.  The  diaphragm  was  higher  on  the  right  side 
than  on  the  left.      Heart  enlarged  on  the  right  side.     (See  Fig.  109.) 

April  I.      No  signs  by  physical  examination. 

April  I.  X-ray  examination  zvith  screen  (no  cut  given)  showed  the 
whole  of  the  right  side  less  clear  than  the  left ;  excursion  of  the  dia- 
phragm on  this  side,  from  the  middle  of  the  fourth  intercostal  space  to 
about  the  middle  of  the  fifth  intercostal  space,  in  the  nipple  line,  2  cen- 
timetres. On  the  left  side  the  shaded  area  seen  at  the  examination  of 
March  24  could  still  be  made  out,  though  it  was  much  less  marked ; 
excursion  of  the  diaphragm  from  the  upper  border  of  the  fifth  rib  to 
above  the  upper  border  of  the  sixth  rib,  2.5  centimetres. 

April  8.     No  physical  signs. 

April  8.  X-Ray  Examination  with  Screen.  —  Right  apex  darker  than 
left ;  excursion  of  the  diaphragm  3.5  centimetres  from  upper  border  of 
fifth  rib  to  about  the  middle  of  the  fifth  space.  On  the  left  side  there 
was  still  a  small  shaded  area  over  the  third  rib  ;  excursion  of  the  dia- 
phragm from  the  upper  border  of  the  fifth  rib  to  the  middle  of  the  fifth 
space,  4  centimetres.     (See  Fig.  no.) 

April  12.  No  physical  signs.  Signs  by  X-ray  examination  about 
the  same  as  on  April  8.     Patient  discharged  from  the  hospital. 

It  would  be  instructive  to  follow  the  X-ray  appearances  in  pneumonia 
longer  than  I  have  usuallv  been  able  to  do,  but  the  patients  become 
so  well  that  they  are  unwilling  to  remain  in  the  hospital,  although  by 
the  X-ray  examination  the  lungs  are  by  no  means  clear  when  they 
go  out. 

Excursion  of  Diaphragm  limited  by  Adhesions.  —  The  movements  of 
the  diaphragm  may  be  limited  by  two  causes  :  first,  by  the  failure  of  the 
lungs  to  expand  to  their  normal  extent  during  deep  inspiration,  because 
of  the  increased  density,  as  already  stated  ;  and  second,  on  account  of 
pleuritic  adhesions.  When  the  patient  is  convalescing  from  pneumonia, 
and  the  lung  has  become  quite  clear,  we  sometimes  find  that  the  excur- 
sion of  the  diaphragm  has  not  reached  its  normal  limit.  If  this  limita- 
tion is  not  due  to  the  former  cause,  it  may  well  be  due  to  the  presence  of 
pleuritic  adhesions.  The  following  case,  with  its  accompanying  tracings, 
illustrates  this  point. 


PNEUMONIA 


i8i 


Tracings  were  made  from  the  chest  of  the  patient  on  October  4,  7, 
10,  and  17,  1899,  and  April  21,  1900.  Copies  of  these  are  given  below, 
with  the  exception  of  that  made  on  October  10. 

Case  I.  Simon  G.,  fourteen  years  old,  entered  the  service  of  one 
of  my  colleagues  at  the  hospital  September  25,  1899,  and  soon  after 
came  under  my  care.      Diagnosis  :  pneumonia. 

Illness  of  five  days'  duration.  Patient  had  sharp  pain  in  left  chest, 
with  sUght  cough,  raising  nothing. 


Pneujnowa     Lef/- Jjcfe 
Oc/bher^th  j^^^ 


Fig.  III.  Simon  G.  Oct.  4,  1899.  Cut  of  first  X-ray  tracing.  Pneumonic  process  in  left  chest. 
Shaded  left  lung  and  restricted  movement  of  left  diaphragm.  X-rays  indicated  that  there  had  been 
some  pneumonia  on  right  side  also,  as  shown  by  shortened  excursion  of  diaphragm  ;  but  it  was  not 
detected  by  physical  signs.     (One-third  life  size.) 

PJtysical  Exaviination.  —  Resonance  and  respiration  good  throughout 
both  fronts ;  an  occasional  sonorous  rale ;  below  the  level  of  angle  of 
left  scapula,  dulness,  bronchial  respiration,  whispered  and  spoken  bron- 
chophony, and  subcrepitant  rales ;  tactile  fremitus  slightly  increased  at 
left  base. 

Temperature  at  entrance  103:],  pulse  no,  respirations  40. 

On  the  seventh  day  of  the  disease  temperature  fell  by  crisis  to 
normal.      Slight  cough  with  greenish  expectoration. 

October  4,  1899.  X-ray  exavimatioji  zvith  screen  showed  a  pneu- 
monic process  which  had  not  yet  cleared  from  the  left  chest.     It  also 


1 82     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

suggested  that  there  had  been  some  pneumonia  on  the  right  side  which 
had  not  been  detected  by  the  physical  examinations.     (See  Fig.  in.) 


Jjjnon  C 
Pnewnojiici     Le/rta/yg 
Oc/dher  7^  J6$9 


J^r- 


Fig.  112.    Simon  G.     October  7.     Cut  of  second  X-ray  tracing.    Shaded  area  diminished ;  movement 
of  diaphragm  increased  on  both  sides.     (One-third  Hfe  size.) 


October  10.    The  lungs   were  clear  by   physical  examination.      No 
cough. 


Pj]e(ijnonio       leftside 
Oc/o/jer  17—  /69S 


Fig.  113.  Simon  G.  October  17.  Cut  of  third  X-ray  tracing.  Both  lungs  nearly  alike  in  bright- 
ness. Diaphragm  on  left  side  moves  more  than  at  last  X-ray  examination,  but  its  movement  is  not  yet 
normal.    This  abnormality  may  be  due  to  pleuritic  adhesions.     (One-third  life  size.) 


PNEUMONIA 


183 


October  15.  Physical  signs  had  all  disappeared.  Patient  out  of  doors 
each  day. 

October  17,  1899.  X-Ray  Exaviination  with  Screen.  —  Both  sides 
nearly  alike  in  brightness,  but  it  will  be  seen  that  the  excursion  of  the 
diaphragm  on  the  left  side  was  less  than  half  as  much  as  that  on  the 
right.     (See  Fig.  113.) 

Patient  now  complains  of  pain  about  the  left  nipple  xvJien  lie  sneezes, 
which  is  probably  due  to  dry  pleurisy,  that  may  limit  the  expansion  of 
the  lung  and  the  excursion  of  the  diaphragm. 

April  21,  1900.  The  patient  returned  to  the  hospital  at  my  request, 
for  a  further  X-ray  examination,  the  result  of  which  is  shown  in  the 
followins:  cut. 


3jinon  C. 
Pneumo/ju  /n  Oep/ 1399 


I 


Fig.  114.     Simon  G.     April  21,  1900.     Fourth  X-ray  tracing.     (One-third  life  size.) 


Pneumonia  with  Obscure  Physical  Signs.  —  A  pneumonia  in  its  early 
stages,  or  even  through  its  whole  course,  may  give  no  signs  by  ausculta- 
tion and  percussion,  and  the  physician  may  find  it  difficult  to  make  the 
diagnosis.  In  some  of  these  cases  a  doubtful  diagnosis  may  be  made  a 
more  certain  one  by  the  use  of  the  X-rays.  This  point  could  be  illus- 
trated by  citing  a  number  of  cases  of  central  pneumonia,  but  three  will 
be  sufficient,  in  which  the  diagnosis  was  made  clear  and  definite  by  an 
X-ray  examination,  and  in  which  this  diagnosis  was  confirmed  by  the 


184    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

subsequent  history  of  the  case ;  the  termination  of  the  fever  by  a  crisis ; 
rusty  expectoration  ;  or,  in  some  cases,  by  the  development  of  physical 
signs  of  pneumonia  as  the  disease  progressed. 

CfamB 
Cen/'rnf  Pneo/nonia 
Ric/ht3jde 
-Teh  2-^ 


Fig.  115.  Clara  B.  February  2.  First  X-ray  tracing.  Central  pneumonia  of  right  side  in  girl 
eight  years  old.  Shaded  lung  and  shortened  excursion  of  diaphragm  on  right  side.  (One-third 
life  size.) 

Case  I.  Clara  B.,  a  child  eight  years  of  age,  entered  my  service 
at  the  hospital  with  a  high  temperature  ;  a  leucocytosis  (25,000);  pain 


0 


CfaraB 
Centra  f  Pnea/naiUl 

'  Feb  /3A 


Fig.  ii6.    Clara  B.     February  13.     Second  X-ray  tracing  with  screen.     Lung  clear;  good  ex- 
cursion of  diaphragm.     (One-third  life  size.) 

and  stiffness  in  the  back  of  the  head  and  neck,  the  neck  so  rigid  that  it 
could  not  be  flexed.     She  did  not  know  how  long  she  had  been  ill,  and 


PNEUMONIA  185 

no  friends  came  to  visit  her.  There  was  no  history,  and  no  physical 
signs  were  found  in  the  chest  after  a  careful  examination  by  two  phy- 
sicians. My  house  physician  also  found  nothing  in  the  lungs,  and  I 
was  inclined  to  accept  the  diagnosis  of  cerebro-spinal  meningitis  which 
had  been  made  by  the  physicians  who  had  seen  the  patient.  I  made  an 
X-ray  examination,  however  (see  Fig.  115),  in  order  to  obtain  further 
information,  and  found  a  dark  area  over  one  lobe  and  a  shortened 
excursion  of  the  diaphragm  on  that  side  ;  and  the  diagnosis  of  pneu- 
monia was  made  without  hesitation.  This  diagnosis  was  confirmed  later 
by  a  marked  crisis,  and  by  a  rapid  clearing  of  the  lung  as  determined  by 
X-ray  examinations.  (See  Fig.  116.)  At  no  time  during  the  course  of  the 
disease  did  I  obtain  signs  of  pneumonia  by  auscultation  and  percussion. 

Case  II.  Elizabeth  B.,  thirteen  years  old,  entered  my  service  at 
the  hospital  November  22,  1898.  Admission  diagnosis:  typhoid  fever 
and  bronchitis. 

Illness  of  seven  days'  duration  ;  came  on  by  a  chill,  followed  by 
fever  ;  headache  ;  pain  in  legs  ;  weakness  ;  pain  in  shoulder  ;  no  cough. 

Physical  Examination.  —  Heart :  area  and  action  normal.  Lungs  : 
respiratory  sounds  and  resonance  normal.  Temperature  105,  pulse  130, 
respirations  35. 

Novcnibcj-  23.  VVidal  test  positive  ;  positive  again  on  November  30, 
and  again  on  December  5. 

November  25.  Respirations  48.  During  the  next  eight  days  they 
ran  from  45  to  50.     Temperature  about  103. 

Nove^nber  29.    Leucocyte  count  17,000. 

December  4.    Temperature  fell  by  crisis, 

December  7.  X-Ray  Examination  zvith  Screen.  —  Both  lungs  darker 
than  normal,  especially  on  the  right  side.  Excursion  of  the  diaphragm 
very  limited,  being  1.25  centimetres  on  the  right  side  and  2.5  centi- 
metres on  the  left  side. 

The  sudden  onset,  chill,  fever,  the  leucocyte  count  of  17,000,  the 
rapid  respirations,  and  the  fall  of  temperature  by  crisis  all  confirmed 
the  appearances  of  a  pneumonia  (accompanying  the  typhoid)  found  in 
the  lungs  by  X-ray  examination. 

Pneumonia  in  Old  People.  — In  such  cases  the  diagnosis  of  pneu- 
monia offers  difficulties  which  are  not  generally  encountered  in  younger 
patients.  As  is  well  known,  pneumonia  may  occur  in  old  patients  with- 
out the  presence  of  fever,  and  the  physical  signs  may  not  be  well  marked, 
or  may  be  such  that  the  physician  makes  some  other  diagnosis. 


1 86     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Case  III.  Julia  F.,  seventy-seven  years  old,  entered  the  service  of 
one  of  my  colleagues  at  the  Boston  City  Hospital  September  30,  1899, 
and  soon  after  came  under  my  care.  The  physical  signs  were  such 
that  I,  as  well  as  the  physician  who  had  charge  of  her  prior  to  me, 
thought  she  had  a  bronchitis  and  did  not  recognize  the  pneumonia.  I 
made  an  X-ray  examination,  as  she  had  an  arterio-schlerosis  with  calci- 
fication of  the  right  radial  artery,  with  a  view  to  determining  whether 
or  not  the  aorta  was  also  calcified.  The  fluorescent  screen  showed  that 
the  whole  of  the  right  side  was  dark  below  the  level  of  the  second  rib, 
and  this  darkness  indicated  that  the  lung  was  increased  in  density. 
Another  careful  physical  examination,  given  below,  and  made  after  the 
X-ray  examination,  indicated  that  we  might  have  to  do  with  a  pneumonia 
in  the  lower  and  middle  portion  of  the  right  lung. 

Physical  Examination.  —  Respiration  harsh  throughout  both  lungs, 
with  numerous  sibilant  and  sonorous  rales  over  all.  Slight  dulness  at 
left  apex  behind  and  over  whole  lower  right  back.  Few  rather  fine  moist 
rales  in  left  axillary  region  ;  medium  and  coarse  moist  rales  over  lower 
two-thirds  of  right  lung  front  and  back.  Tactile  fremitus  more  marked 
over  lower  right  back. 

Temperature  normal  or  subnormal  during  her  three  weeks'  stay  at 
the  hospital;  pulse  90;  respirations  34  on  October  i,  and  25  on  Octo- 
ber 2,  after  which  time  they  were  about  normal. 

The  following  tracing  gives  the  condition  of  the  chest  as  seen  at 
the  first  X-ray  examination,  made  on  October  5 ;  and  the  second  as  seen 
on  November  7,  when  the  right  lung  had  cleared  up. 

These  three  cases  show  how  the  X-ray  examination  may  assist  in 
pointing  out  an  abnormal  condition  of  the  lungs  when  it  is  either  not 
clearly  shown  by  auscultation  and  percussion,  or  is  not  recognized  by 
these  methods  of  examination. 

Differential  Diagnosis.  —A  familiarity  with  the  appearances  of  the 
lungs  in  pneumonia  is  necessary  in  order  to  make  a  differential  diagnosis 
between  this  and  some  other  disease. 

a.  Pleurisy  with  Effusion  or  Pneumonia.  —  In  some  patients  the 
physical  signs  may  be  such  that  it  is  difficult  to  decide  whether  we  have 
a  pleurisy  with  effusion  or  a  pneumonia,  but  if  the  area  of  lung  involved 
is  not  sufficient  to  prevent  us  from  seeing  the  outline  of  the  diaphragm 
in  full  inspiration,  that  is,  if  the  fluorescent  screen  shows  a  lighter  area 
below  the  dark  pneumonic  one,  we  may  be  sure  that  no  liquid  is  present 
unless  it  be  much  above  the  diaphragm  and  encysted,  an  uncommon 


PNEUMONIA 


187 


Oc/cihers^ 


Fig.  117.    Julia  F.    October  5.     First  X-ray  tracing.     Pneumonia,  right  side.     Diaphragm  lines 
obliterated  on  this  side.     (One-third  lite  size.) 


KJaha  F    77^rs 
fnea/nonici 
JVoy  7^ 


Fig.  118.    Julia  F.     November  7.    Second  X-ray  tracing.     Lung  clear ;  diaphragm  lines  seen.     (One- 
third  life  size.) 


1 88    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

condition.  If  a  change  in  the  position  of  the  patient,  while  looking 
through  the  chest,  shows  a  difference  in  the  shape  of  the  shadow,  we 
have  to  do  with  liquid  rather  than  solid.  Further,  an  extensive  pneumonia 
of  one  side  may  be  distinguished  from  a  large  pleuritic  effusion  by  the 
position  of  the  border  of  the  heart,  as  the  displacement  of  this  organ 
when  liquid  is  present  is  much  greater  than  in  pneumonia.  The  enlarge- 
ment of  the  heart  in  pneumonia  should  not  be  overlooked  in  this  con- 
nection. 

Case  I.  Essie  L.,  eighteen  years  old,  entered  my  service  at  the 
hospital  February  28,  1899.     Diagnosis:  pneumonia. 

Present  Illness.  —  Cough  for  two  weeks.  Seven  days  before  entrance 
began  to  have  pain  in  left  side,  much  increased  by  cough  or  deep 
inspiration.  No  chill  or  other  pain.  Expectoration  tinged  with  blood 
for  two  days. 

Physical  Examination.  —  Heart  :  right  border  4  centimetres  to  right 
of  midsternum,  left  border  8.5  centimetres  to  left  of  midsternum  ;  apex 
in  fifth  space  inside  nipple  line  ;  action  regular  ;  no  murmurs.  Lungs  : 
resonance  and  respiration  good  over  fronts  and  right  back  ;  over  left 
back  respiration  good  at  apex,  bronchial  between  spine  and  inferior  arch 
of  scapula,  and  absent  below  angle.  Tactile  and  vocal  fremitus  absent 
below  angle  of  scapula.     Temperature  103,  pulse  no,  respirations  40. 

March  6.  Temperature  fell  to  normal ;  pulse  and  respirations  also 
fell. 

X-ray  examinations  ivith  screen  were  made  on  March  i,  6,  23,  and  30, 
but  I  give  cuts  of  only  two  of  these  examinations. 

March  i.  X-Ray  Examination  with  Screen  (Fig.  119).  —  In  the  first 
cut  it  will  be  seen  that  the  right  border  of  the  heart  (probably  dilated) 
is  farther  to  the  right  than  normal,  but  no  farther  than  we  might  expect 
to  find  it  in  pneumonia.  The  apex  beat  is  just  inside  the  line  of  the  left 
nipple  and  therefore  the  heart  is  not  displaced  to  the  right,  but  simply 
enlarged  on  that  side,  and  we  probably  have  to  deal  with  a  pneumonia 
only,  and  not  with  a  pleurisy  with  effusion. 

March  6.  Second  X-Ray  Examination  with  Screen.  —  The  second 
cut  (Fig.  120)  shows  the  right  lung  clearer  than  at  the  first  examination, 
and  the  right  heart  in  its  normal  position.  On  the  left  side  of  the  chest 
the  dark  area  is  more  sharply  defined  than  in  pleurisy  with  effusion,  and 
moves  up  and  down  with  the  respiration,  as  indicated  on  the  tracing, 
the  wavy  broken  line  indicating  the  position  of  the  shadow  in  expiration, 
and  the  full  one  in  inspiration. 


PNEUMONIA 


1S9 


^J3/e  L 

Pneu/no/j/a 
March  Jit 


Fig.  119.     Essie  L.    March  i.     First  X-ray  tracing.     Pneumonia,  left  side.    Darkened  left  lung. 
Right  border  of  the  heart  farther  to  right  than  normal.     (One-third  life  size.) 


£33/e  I 
Pneamojiia 
March  6  tit. 
Fig.  120.     Essie  L.     March  6.     Second  X-ray  tracing.     Broken  line  shows  position  of  darkened  area 
in  expiration;  full  line  in  inspiration.    Right  heart  in  normal  position.     (One-third  life  size.) 


I90     THE   ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 

March  23.  The  third  X-ray  examination  (no  cut  given)  showed  the 
lungs  comparatively  clear  on  both  sides. 

It  will  be  seen  from  the  following  case  how  an  X-ray  examination 
may  assist  in  distinguishing  a  pneumonia  in  the  lower  part  of  the  chest 
from  a  pleurisy  with  effusion,  though  some  of  the  physical  signs  may 
favor  the  latter  diagnosis. 

Case  II.  Joseph  S.,  seventeen  years  old,  entered  my  service  at  the 
hospital  April  29,  1899.     Diagnosis:  pneumonia. 

He  had  a  chill  two  days  before  entrance  ;  much  cough  and  expectora- 
tion; pain  in  the  left  side,  worse  on  deep  inspiration;  headache;  vomiting. 


^03eph  3 
Pneumonia 

Fig.  121.  Joseph  S.  May  i.  Pneumonia.  Question  of  pleuritic  fluid.  X-ray  examination 
with  screen  showed  there  was  no  fluid  in  either  pleural  sac,  as  the  outlines  of  the  diaphragm  were 
clearly  seen,  and  the  shadow  did  not  change  its  shape  when  the  patient  changed  his  position.  (One- 
third  life  size.) 


Physical  Examination.  —  Heart:  right  border  3.5  centimetres  to  the 
right,  and  left  border  6  centimetres  to  the  left  of  the  median  line ;  apex 
in  fifth  space,  6.5  centimetres  to  left  of  median  line;  action  regular;  no 
murmurs.  Lungs  :  resonance  good  except  at  bases,  where  it  is  fiat ; 
respiration  good  except  at  bases,  where  it  is  feeble,  and  tactile  and  vocal 
fremitus  diminished  ;  coarse  friction  rub  in  lower  left  axilla. 

It  was  a  question  whether  we  had  or  had  not  to  do  with  fluid  in  one 
or  both  pleural  cavities. 

May  I.  X-ray  examination  zvith  scj'ecn  (Fig.  121,  Joseph  S.)  showed 
clearly  that  there  was  no  fluid  in  either  pleural  sac,  as  the  outHnes  of  the 


PNEUMONIA 


191 


diaphragm  were  clearly  seen,  and  the  shape  of  the  shadow  did  not 
change  when  the  patient  changed  his  position. 

Case  III.  George  B.,  thirty-six  years  old,  entered  the  hospital  in 
September,  1896.     Service  of  Dr.  George  B.  Shattuck. 

This  patient  had  a  pneumonia  in  the  lower  portion  of  the  left  lung, 
which  began  ten  days  before  entrance. 

X-Ray  Exajnination  zvitli  Screen.  —  I  found  the  right  side  was  per- 
fectly clear ;  heart  not  displaced  ;  on  the  left  side,  from  the  third  rib 
downward,  the  shadow  was  so  dark  that  the  outline  of  the  heart,  ribs, 
and  diaphragm  was  wholly  obscured. 

The  apex  of  the  heart  was  felt  in  normal  position,  indicating  that  this 
organ  was  not  displaced.  I  therefore  considered  that  the  shadow 
on  the  screen  was  due  to  the  presence  of  the  pneumonia  rather  than 
to  fluid  in  the  pleural  cavity. 

This  case  illustrates  how  palpation  and  X-ray  examination  may 
supplement  each  other. 

b.  Pneumonia  or  Tuberculosis.  —  The  history  and  usual  methods  of 
examination  generally  enable  us  to  distinguish  readily  between  these 
diseases,  but  there  are  exceptions  to  this  general  rule  in  which  the  X-rays 
may  be  of  assistance.  The  examination  with  the  fluorescent  screen 
may  aid  us  in  discriminating  between  pneumonia  and  tuberculosis  in 
those  cases  in  which  the  patient  has  had  a  pneumonia  at  the  apex  some 
weeks  before  entering  the  hospital,  of  which  the  physician  gets  no  his- 
tory. If  the  disease  is  pneumonia,  rapid  improvement  would  probably 
be  seen  in  the  lungs  at  successive  X-ray  examinations  made  at  intervals 
of  a  few  days  or  a  week,  whereas  a  tuberculous  process  would  not  be 
likely  to  show  this  rapid  gain.  The  X-ray  examination  may  also  assist 
by  pointing  out  the  position  of  the  pulmonary  density. 

The  above  cases  show  that  more  than  one  X-ray  examination  is  neces- 
sary to  determine  the  diagnosis  in  many  cases,  and  also  indicate  how  we 
may  discriminate  between  an  enlarged  and  a  displaced  heart,  which  is  an 
important  question,  and  will  be  discussed  in  the  chapter  on  the  Heart. 

Pneumonia  with  "La  Grippe."  —  I  have  found,  by  means  of  an  X-ray 
examination,  appearances  in  the  lungs  of  some  of  my  patients  who  had 
influenza,  that  led  me  to  suppose  they  also  had  pneumonia,  although  no 
signs  of  pneumonia  could  be  found  by  auscultation  and  percussion. 
Later,  however,  the  diagnosis  suggested  by  the  X-ray  examination  was 
confirmed  by  the  physical  signs  or  the  progress  of  the  disease.  In 
other  words,  some  cases  of  influenza  are  accompanied  by  a  pneumonia 


192     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

which  is  not  sufficiently  marked  at  first  (in  certain  of  them  not  at  any 
stage)  to  be  determined  by  the  usual  physical  signs,  and  there  may  be 
no  ieucocytosis.  X-ray  examinations  have  shown  me  the  necessity  of 
keeping  patients  in  bed  whom  I  should  otherwise  have  allowed  to  get 
up,  and  of  detaining  them  in  the  house  longer  than  would  have  seemed 
requisite  if  this  condition  of  the  lungs  had  not  been  recognized. 

Severe  Cold.  —  Individuals  with  apparently  a  severe  cold,  only,  may 
sometimes  show  dark  areas  in  the  lungs,  indicating,  perhaps,  a  slight 
pneumonia,  which  should  warn  the  physician  to  see  to  it  that  this 
patient  carefully  avoids  further  exposure  for  some  days  at  least. 

Empyema  overlooked.  —  All  physicians  of  experience  know  that  an 
empyema  after  pneumonia  may  be  overlooked,  but  the  failure  to  recog- 
nize this  condition  could  hardly  occur  were  X-ray  examinations  made,  as 
fluid  in  the  pleural  sac  would  cause  a  marked  shadow  on  the  screen,  and 
the  outline  of  the  diaphragm  would  be  obliterated. 

Appendicitis  confounded  with  Pneumonia.  —  It  has  happened  that 
patients  have  been  operated  upon  for  appendicitis  when  no  inflammation 
of  the  appendix  existed.  The  symptoms  simulating  appendicitis  after- 
ward proved  to  be  due  to  pneumonia.  Should  there  be  any  uncertainty 
as  to  the  presence  of  pneumonia  in  any  such  case,  the  doubt  could  be 
set  at  rest  by  an  X-ray  examination. 

Absence  of  Pneumonia  determined.  —  By  means  of  the  X-rays  we  can 
also  absolutely  determine  the  absence  of  pneumonia  in  the  acute  stage. 

Broncho-Pneumonia.  —  In  this  form  of  pneumonia  the  area  involved 
casts  a  well-marked  shadow,  as  I  have  found  by  examination  of  the  lungs 
during  life  with  the  fluorescent  screen,  and  by  examination  of  lungs  taken 
from  the  body  after  death,  both  by  screen  and  X-ray  photograph.  The 
following  case  is  illustrative  :  — 

J  as.  W.  VV.  November  5,  1896.  Broncho-pneumonia  following 
typhoid  fever. 

Autopsy.  —  In  the  lower  lobes  of  both  lungs  and  the  upper  lobe  of 
the  left  lung  there  were  extensive  foci  of  consolidation  around  the 
bronchi.  The  consolidated  areas  were  very  red,  varying  in  size  from 
I  to  2  centimetres  in  diameter.  The  surrounding  lung  tissue  was 
intensely  congested  and  edematous.  Anatomical  diagnosis :  broncho- 
pneumonia of  both  lungs,  partly  confluent. 

The  radiographs  taken  of  these  lungs  showed  a  marked  increase  in 
density,  and  that  the  shadow  cast  by  them  was  much  greater  than  that 
cast  by  normal  lungs. 


CHAPTER    VII 

EMPHYSEMA  OF  THE  LUNGS.     BRONCHITIS 
Emphysema  of  the  Lungs 

Appearances  seen  on  the  Fluorescent  Screen  in  Emphysema.  —  (See 
Fig.  122.)  The  pulmonary  area  is  more  e.xtensive  and  brighter  than  in 
health,  and  reaches  not  only  lower  down  but  higher  up  in  the  chest. 
The  diaphragm  is  lower  down  in  the  thorax,  and  its  excursion  is  re- 
stricted, and  is  restricted  in  the  upper  part  of  its  usual  mov^ement.  It 
sometimes  happens  that  the  diaphragm  is  so  low  down  during  full  inspira- 
tion that  it  has  a  peculiar  outline,  this  outline  being  made  up  of  two 
curves  on  each  side,  instead  of  one,  and  following  the  outline  of  some  of 
the  organs  directly  under  it.  But  though  in  quiet  breathing  the  diaphragm 
may  be  low  down  in  the  thorax,  it  may  be  brought  much  higher  up  in  the 
chest  during  a  forced  expiration.  This  increased  excursion  may  be  caused 
by  the  upward  pressure  of  the  contents  of  the  abdominal  cavity,  a  press- 
ure arising  from  the  contraction  of  the  abdominal  walls.  The  cardiac 
outline,  which  it  is  difficult  and  frequently  impossible  to  obtain  by  percus- 
sion in  pulmonary  emphysema,  stands  out  with  unusual  clearness  on  the 
fluorescent  screen,  as  do  the  other  outlines,  such  as  the  ribs  and  clavicles. 
The  heart  changes  its  position  far  less  than  usual  during  deep  inspira- 
tion ;  it  is  lower  down  in  the  thorax  than  in  health,  so  much  so  that  its 
pulsation  may  be  felt  over  the  ensiform  cartilage,  and  its  long  axis  is  in 
a  more  vertical  position.  The  lower  position  of  the  diaphragm  gives 
the  axis  of  the  heart  when  viewed  both  from  the  front  and  side  of  the 
chest  this  vertical  direction,  and  is  one  of  the  reasons  why  this  organ, 
when  looked  at  from  side  to  side,  is  at  a  greater  distance  from  the 
sternum  in  emphysema  than  in  health.  Frequently  the  right  ventricle 
and  the  right  auricle  are  seen  to  be  enlarged,  and  the  latter  is  more 
clearly  seen,  both  because  the  lungs  are  brighter,  and  the  auricle  is 
larger  than  normal. 

o  193 


194     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

Methods  of  Examination.  —  The  method  of  examining  a  case  of  em- 
physema, and  of  recording  the  observations  made,  are  sufficiently  indi- 
cated in  the  directions  given  for  examinations  of  the  chest  in  Chapters 
III,  V,  and  X. 


Fig.  122.     Diagram  of  emphysema  of  both  lungs  in  full  inspiration.     Broken  lines  show  position  of 
diaphragm  in  expiration.     Nipple  level  indicated  by  heavy  lines  under  axillae. 
Lungs  brighter  and  long  axis  of  heart  more  vertical  than  normal ;  excursion  of  diaphragm  shorter 
than  normal,  and  low  down  m  the  thorax. 

In  this  disease  the  X-rays  may  be  especially  serviceable  ;  they  enable 
us,  even,  to  make  the  diagnosis  of  emphysema  without  the  aid  of  any 
of  the  usual  physical  signs,  and  to  recognize  it  in  some  cases  where  it 
has  been  overlooked  by  these  signs  ;  further,  they  can  assure  us  that  no 
considerable  amount  of  emphysema  is  present  even  when  the  physical 


EMPHYSEMA   OF   THE    LUNGS.     BRONCHITIS 


195 


examination  has  indicated  it.     They  likewise  indicate  to  what  extent  the 
heart  is  enlarged. 

The  following  cases  are  illustrative:  — 

Case  I.  John  S.,  42  years  old,  entered  my  service  at  the  Boston 
City  Hospital  April  6,  1898.  He  had  pleurisy  with  effusion  on  the 
right  side,  the  heart  was  somewhat  displaced  to  the  left ;  and  he  suf- 
fered very  much  from  dyspnoea ;  why,  I  could  not  understand,  since 
the  amount  of  fluid  did  not  seem  to  me  sufficient  to  give  rise  to  the 
dyspnoea. 

An  X-ray  exainmatioji  with  screen,  however,  made  this  clear,  for  I 
found  by  this  means  that  he  had  a  very  marked  and  extensive  emphy- 
sema ;  the  excursion  of  the  diaphragm  on  the  left  side  was  low  down, 
and  had  a  maximum  movement  of  2  centimetres  only. 

Case  \l.  Frank  B.  Entered  the  Boston  City  Hospital  in  Decem- 
ber, 1896.  Service  of  one  of  my  colleagues.  He  was  thought  to  have 
emphysema  and  asthma. 

My  X-Ray  Exaviiiiation  ivith  Screen.  —  No  signs  of  emphysema. 
Remarkably  good  excursion  of  the  diaphragm  :  6.25  centimetres  on  right 
side,  and  7.5  centimetres  on  left  side. 

The  following  case  is  chosen,  not  only  to  illustrate  the  appearances 
seen  in  emphysema,  but  also  because  of  other  conditions  present  which 
give  it  additional  interest :  — 

Case  HI.  Patrick  W.,  forty-seven  years  of  age,  entered  my  ser- 
vice at  the  Boston  City  Hospital  January,  1900,  with  a  diagnosis  of  new 
growth  in  the  lung.  He  gave  a  history  of  a  severe  cold  which  had 
begun  five  weeks  previously,  and  which  had  prevented  him  from  work- 
ing for  the  past  four  weeks.  He  had  had  chills  which  obliged  him  to 
remain  in  bed  for  nine  days  ;  cough,  dull  pains  in  the  right  chest,  slight 
dyspnoea. 

Physical  Examination.  —  Lungs  :  right  lung  does  not  move  as  much  at 
extreme  end  of  inspiration  as  does  left ;  slight  dulness  throughout  right 
back  and  in  front  above  third  rib ;  slight  increase  in  tactile  fremitus  ; 
increased  whispered  and  spoken  voice  ;  no  rales  heard.  Heart :  right 
border  5.3  centimetres  to  right  of  median  line,  left  border  9.5  centime- 
tres to  left  of  median  line.  Pulse  :  of  good  volume  and  tension  ;  slight 
thickening  of  the  radial  arteries. 

January  17.  X-Ray  Examination  xvitJi  Screen.  —  Lungs  brighter  than 
normal  except  for  a  darkened  right  apex,  and  all  outlines  clearer  than 
normal.     Diaphragm  low  down  in  the  chest  and  its  excursion  limited  on 


196    THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

the  upper  side.  Long  axis  of  the  heart  nearly  vertical ;  right  side  en- 
larged ;  little  or  no  difference  in  position  of  heart  in  inspiration  and 
expiration. 


Fig.  123.  Patrick  W.  January  17,  1900.  Emphysema.  First  X-ray  tracing.  Lungs  brighter 
than  normal  except  for  darkened  right  apex.  Diaphragm  low  down  in  chest ;  e.xcursion  limited  on 
upper  side.  Long  axis  of  heart  nearly  vertical,  right  side  enlarged;  little  or  no  difference  in  position 
of  heart  between  inspiration  and  expiration.     (One-third  life  siEe.) 


January  30.  Second X-Ray  Examination  with  Screen  (X-ray  tracing 
not  given).  —  Similar  outlines  to  those  seen  January  17. 

Eight  examinations  of  the  sputa  made ;  no  tubercle  bacilli  found. 

Discharged  February  6. 

May  13,  1900.  Third  X-Ray  Examination  ivith  Screen.  — T\\q  pa- 
tient came  to  me  at  my  request  for  another  examination.     The  apex  of 


EMPHYSEMA   OF   THE    LUNGS.     BRONCHITIS 


197 


the  right  lung  was  clear  (see  Fig.  124),  so  that  it  is  not  improbable  that 
he  had  on  entrance  to  the  hospital  the  remains  of  an  acute  pneumonia 
at  the  right  apex.  It  is  not  probable  that  it  was  tuberculosis,  because 
he  had  improved  in  his  general  condition  and  the  apex  had  cleared  up 
in  so  short  a  time.  The  dotted  lines  indicate  the  point  to  which  the 
diaphragm  rose  in  forced  expiration.      This  high  point  was  probably 


Patrick  W. 

Mau  Iboo 


V .(QJ 


Fig.  124.  Patrick  W.  May  13,  1900.  Third  X-ray  tracing.  Ape.x  of  right  lung  clear,  showing 
that  the  shaded  area  was  probablv  not  due  to  tuberculosis  but  perhaps  to  remains  of  acute  pneumonia. 
Broken  and  full  parallel  lines  indicate  position  of  diaphragm  in  expiration  and  inspiration  respectively; 
dotted  lines  parallel  to  them,  diaphragm  line  in  forced  expiration.     (One-third  life  size.) 

reached,  as  already  suggested,  because  of  the  upward  pressure  of  the 
contents  of  the  abdominal  cavity,  brought  about  by  contraction  of  the 
abdominal  walls. 

This  explanation  would  indicate  that  in  treating  emphysema  the 
abdominal  muscles  should  be  trained  to  assist  in  expiration. 

A  second  X-ray  cxaviination  should  be  made  after  a  week  or  two  if 
there  is  a  question  of  the  diagnosis,  in  order  to  be  sure  whether  or  not 


198     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

the  appearances  seen  are  due  to  emphysema.  For  instance,  in  some 
cases  of  bronchitis  the  excursion  of  the  diaphragm  may  be  low  down  in 
the  chest  and  much  shorter  than  normal,  as  in  emphysema,  but  the  lungs 
would  not  be  clear,  and  as  they  improved  the  excursion  of  the  diaphragm 
would  increase.  If,  then,  bronchitis  were  associated  with  emphysema, 
the  former  disease  would  diminish  the  brightness  of  the  lungs  that 
obtains  in  the  latter,  and  the  emphysema,  therefore,  might  be  over- 
looked at  the  first  examination  and  the  abnormal  excursion  of  the 
diaphragm  attributed  to  the  bronchitis  only,  but  a  second  X-ray  exam- 
ination would  correct  the  first  if  the  bronchitis  had  meanwhile  improved. 

Emphysema  a  Hindrance  to  Percussion.  —  The  following  case  illus- 
trates the  obstacle  which  may  hinder  the  successful  use  of  percussion  in 
emphysema  of  the  lungs:  — 

Case  IV.  Henry  B.,  a  patient  brought  to  me  from  the  out-patient 
department  by  Dr.  H.  D.  Arnold. 

X-Ray  Exaviination  zvith  Screen.  —  The  heart  was  smaller  than  per- 
cussion had  indicated  ;  its  anterior  border  could  be  plainly  seen  when  the 
patient  was  examined  with  the  light  going  through  the  chest  from  side  to 
side,  and  also  a  clear  bright  area  which  separated  the  heart  from  the  ster- 
num (the  patient  was  a  small  thin  man);  the  outside  of  the  chest  was 
5  centimetres  from  the  anterior  border  of  the  heart  when  he  was  stand- 
ing. The  first  three  ribs  were  thickened  where  they  joined  the  sternum, 
and  Dr.  Arnold  found  that  over  this  part  the  percussion  note  changed, 
which  shows  how  a  variation  in  the  thickness  of  the  chest  wall  may  alter 
the  percussion  note.  This  note  had  misled  him  in  determining  part  of 
the  cardiac  outline. 

A  radiograph  was  also  taken  of  this  patient,  which  shows  the 
appearances  seen  from  the  side.     (See  Fig.  125.) 

Physical  Signs  of  Tuberculosis  hidden  by  Emphysema ;  Abnormal 
Condition  of  Lungs  seen  by  X-Rays.  —  The  same  cause  that  makes  it 
difficult  or  impossible  to  recognize  the  cardiac  area  in  pulmonary  emphy- 
sema by  percussion  affects  the  usefulness  of  this  method  where  this  dis- 
ease is  accompanied  by  a  pulmonary  tuberculosis,  and  not  infrequently 
I  have  found  dense  pulmonary  areas  readily  by  an  X-ray  examination 
when  they  were  not  obtained  by  auscultation  and  percussion.  Where 
emphysema  and  pulmonary  tuberculosis  occur  together,  the  emphysema 
may  conceal  the  physical  signs  of  tuberculosis.    (See  pages  140  and  141.) 

The  X-rays  then  offer  an  additional  means  of  examining  the  chest 
in  cases  of  emphysema  where  tuberculosis  is  suspected,  and  they  may 


Fig.  125.  Henry  B.  Patient  with  well-marked  emphysema.  Liijht  area  in  radiograph,  which  was 
taken  in  quiet  breathing,  shows  that  the  heart  was  at  some  distance  from  the  chest  wall.  The  patient 
was  sitting  up  when  the  radiograph  from  which  this  lialf-tone  was  made  was  taken,  and  the  tube  was 
placed  on  a  level  with  the  heart  and  opposite  the  left  side  of  the  patient,  so  that  tlie  light  went  through 
the  chest  from  one  side  to  the  other,  but  in  front  of  the  heart.  The  plate  was  placed  against  the  side 
of  the  chest  away  from  the  light.    Heart  may  also  be  pushed  forward  in  emphysema.    (See  Appendix.) 


200     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

show  signs  of  consolidation  where  they  had  not  been  suspected  ;  or 
they  may  show  that  the  hmgs  are  perfectly  clear,  although  auscultation 
and  percussion  had  given  cause  for  suspicion  of  pulmonary  tuberculosis. 

Bronchitis 

The  number  of  cases  of  bronchitis  which  I  have  had  an  opportunity 
of  examining  is  not  large,  about  twenty-five  in  all.  It  has  been  diffi- 
cult to  get  more  than  one  examination  in  most  of  these  cases,  and  I 
have,  therefore,  not  been  able  to  determine  what  changes  take  place  in 
the  appearances  on  the  screen  as  the  patients  improve. 

Appearances  seen  on  the  Fluorescent  Screen  in  Bronchitis.  —  In  some 
of  these  patients  the  whole  chest  was  less  clear  than  normal  ;  that  is 
to  say,  the  ribs  and  outlines  of  the  organs  were  less  well  marked  than 
in  health.  In  fifteen  cases  the  excursion  of  the  diaphragm  was  about 
normal ;  in  nine  it  was  more  or  less  limited  on  both  sides  ;  and  in  the 
remaining  case  I  have  no  record  of  its  movement. 

I  have  observed  the  effects  of  obstruction  to  the  air  passages  on  the 
screen  in  a  few  cases,  and  they  seem  to  give  a  hint  which  may  explain 
the  appearances  seen  in  some  cases  of  bronchitis.  When  the  air  pas- 
sages are  obstructed  by  a  foreign  body  in  one  bronchus  the  excursion  of 
the  diaphragm  may  be  limited  on  that  side  and  limited  as  in  emphysema; 
that  is,  its  excursion  is  rather  low  down  in  the  chest.  I  have  seen  the 
same  appearances  where  the  bronchus  was  probably  pressed  upon  on 
the  left  side  by  an  aneurism,  and  another  where  a  new  growth  obstructed 
the  trachea;  in  this  last  case  both  lungs  were  distended  to  their  fullest 
extent,  and  the  diaphragm  moved  very  little.     (See  pages  347-349-) 

The  following  case  is  illustrative  :  — 

Henry  McC,  nine  years  old,  entered  the  hospital  November  6,  1899. 
Service  of  Dr.  John  C.  Munro.  Three  weeks  before,  while  eating  a  small 
walnut,  he  swallowed  a  portion  of  the  shell,  which  lodged  apparently 
in  the  right  bronchus.  He  soon  developed  pneumonia,  which  lasted 
ten  days.  At  entrance  to  the  hospital  there  were  no  subjective  symp- 
toms except  that  every  morning  he  coughed,  and  raised  considerable 
matter  on  getting  up.  A  physical  examination  on  the  right  side 
showed  general  dulness  and  diminished  respiration. 

November  7.  X-Ray  Examination.  —  I  examined  this  patient  with 
the  fluorescent  screen,  and  saw  no  signs  of  consolidation  of  the  right 
lung  except  over  a  small  narrow  area  between  the  third  and  fourth 
interspace,  extending  downward  and  to  the  right  from  the  median  line. 


EMPHYSEMA    OF   THE    LUNGS.     BRONCHITIS 


20 1 


The  excursion  of  the  diaphragm  was  much  shorter  on  this  side  than 
on  the  left.     (See  Fig.  126.) 

November  24.      Dr.  John  C.  Munro  did  tracheotomy  and  withdrew  the 
piece  of  nutshell,  and  on  December  2  the  patient  was  discharged. 


/^enry  McC 
Bece  oJ-Wafnahn  Rihh  I'  Bronchia 


© 


Fig.  126.  Henry  McC.  November  7,  1899.  X-ray  examination  with  screen  before  removal 
of  walnut  shell ;  excursion  of  diaphragm  shortened  on  right  side. 

I  sent  for  this  boy  after  his  discharge  from  the  hospital,  and  made 
another  X-ray  examination  of  the  chest.  This  examination  showed  a 
good  excursion  of  the  diaphragm  on  the  right  side,  the  same  length 
as  on  the  left. 

In  bronchitis,  especially  of  an  acute  or  sub-acute  form,  or  a  bron- 
chitis following  measles,  the  shortened  excursion  of  the  diaphragm,  and 
the  restriction  of  its  movement  to  the  lower  part  of  the  chest,  may  be  due 
to  the  obstruction  of  the  smaller  air  passages  ;  and  the  somewhat  shaded 
pulmonary  area  to  a  marked  pulmonary  congestion,  and  the  increased 
secretion  obtaining  in  bronchitis.  It  follows,  therefore,  that  in  making 
a  diagnosis  where  such  acute  conditions  are  present,  we  should  try 
the  effect  of  coughing  on  the  movement  of  the  diaphragm,  for  if,  after 
the  passages  have  been  relieved  of  mucus,  the  excursion  increases,  the 
indications  are  in  favor  of  a  bronchitis  instead  of  an  emphysema,  but 
we  may  not  be  able  to  establish  the  diagnosis  until  after  two  or  three 
X-ray  examinations  have  been  made  with  an  interval  between  them. 


CHAPTER    VIII 

PLEURISY   WITH    EFFUSION.      EMPYEMA 

Appearances  seen  on  the  Fluorescent  Screen  in  Pleurisy  with 
Effusion.  —  I  will  begin  this  chapter  by  quoting  a  few  lines  from  an 
article  I  published  October  i,  1896/  as  it  is  interesting  to  see  how  much 
could  be  seen  even  in  the  early  days  of  the  X-rays  :  — 

"  In  pleurisy  with  effusion  the  outline  of  the  diaphragm  in  the 
fluoroscope  is  less  defined,  or  obliterated  altogether,  according  to  the 
amount  of  fluid  present,  as  are  also  some  of  the  ribs  in  the  upper  por- 
tion of  the  affected  side ;  the  lung  is  also  denser,  being  compressed  by 
the  fluid,  if  there  is  much  effusion.  I  observed  in  one  case  that  the 
line  separating  the  fluid  surrounding  the  lower  part  of  the  lung  from 
the  compressed  upper  portion  ran  from  about  the  junction  of  the  sixth 
rib  with  the  sternum  toward  the  outer  end  of  the  clavicle." 

While  this  line  is  in  no  sense  sharply  defined,  it  is  often  more  definite 
when  the  patient  is  examined  in  a  sitting  position  than  when  lying  down. 
A  very  marked  displacement  of  the  heart,  when  there  is  any  consider- 
able amount  of  fluid  present,  is  another  striking  feature  to  be  seen  on 
the  fluorescent  screen  in  pleurisy,  the  displacement,  as  a  rule,  given  the 
same  amount  of  fluid,  being  greater  when  the  fluid  is  on  the  left  side 
of  the  chest  and  the  heart  is  displaced  to  the  right,  than  when  the  fluid 
is  on  the  right  side  of  the  chest  and  the  heart  is  displaced  to  the  left. 
Further,  the  triangle  below  and  behind  the  heart,  described  on  page  258, 
is  seen  to  be  wholly  or  largely  obliterated  according  to  the  amount  of 
effusion  present.  The  following  cuts,  made  from  diagrams,  show  the 
picture  seen  on  the  fluorescent  screen  :  first,  in  pleurisy  with  a  small 
effusion  of  the  right  side  (Fig.  127);  and  second,  in  pleurisy  with  a  large 
effusion  of  the  same  side  (Fig.  128). 

1  "  A  Method  for  more  fully  determining  the  Outline  of  the  Heart  by  Means  of  the  Fluoro- 
scope, together  with  Other  Uses  of  this  Instrument  in  Medicine."  Boston  Medical  and  Surgical 
Journal,  October  i,  1896. 


PLEURISY    WITH    EFFUSION.     EMPYEMA  203 

It  will  be  noted  in  Fig.  127  that  the  diaphragm  hne  could  not  be  seen 
on  the  affected  side,  and  the  lower  part  of  the  chest  was  dark  on  this 
side. 

Figure  128  shows  the  affected  side  dark  throughout.  No  diaphragm 
or  ribs  visible.     The  heart  is  much  displaced  to  the  left;  the  diaphragm 


Fir,.  127.     Diagram  ot  pleurisy,  with  small  eftubion ;  inspiration. 
Lower  portion  of  right  lung  darkened  by  the  effusion  and  diaphragm  lines  obliterated  on  this 
side.     Broken  lines  on  left  side  show  position  of  heart  and  diaphragm  in  expiration. 

pushed  down  on  that  side  and  its  excursion  diminished.  After  the 
X-ray  examination  with  the  screen  was  made  in  this  case,  I  drew  off  126 
ounces  of  fluid.  The  heart  then  returned  to  a  more  normal  position, 
and  the  excursion  of  the  diaphragm  on  the  left  side  increased   and  this 


204     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

muscle  went  higher  up  in  the  chest.  The  fluid  had  pressed  the  heart  to 
the  left,  and  the  left  half  of  the  diaphragm  had  been  crowded  or  pulled 
down,  and  interfered  with  the  action  of  the  left  lung. 


Fig.  128.     Diagram  of  pleurisy,  with  large  effusion;  inspiration.     Broken  lines  show  position  of  dia- 
phragm in  expiration. 

Right  side  darkened  throughout  by  presence  of  fluid.  Heart  pressed  to  left  by  fluid  and  action 
of  left  lung  interfered  with.  After  four  litres  had  been  drawn  from  the  right  side,  the  excursion  of  the 
diaphragm  on  the  left  side  became  much  greater  and  was  higher  in  the  thorax. 

A  downward  displacement  of  the  liver  may,  of  course,  take  place 
with  a  large  effusion,  but  an  X-ray  examination  would  not  be  necessary 
to  detect  this. 

When  the  fluid  partially  fills  the  pleural  sac  but  does  not  extend  to 
the  upper  part  of  the  chest,  we  may  still  expect  to  find  the  apex  of  the 


PLEURISY   WITH    EFFUSION.     EMPYEMA  205 

lung,  on  the  diseased  side,  somewhat  darker  than  that  on  the  normal 
side,  owing  to  the  fact  that  the  first  lung  is  compressed,  and  is  thus  a  little 
denser  than  that  on  the  well  side. 

The  appearances  in  empyema  would  be  similar  to  those  seen  in 
some  cases  of  pleurisy  with  effusion.  This  point  is  illustrated  by  the 
following  experiment  made  in  1896.  I  placed  under  the  fluorescent 
screen  a  vulcanite  cup  full  of  pus,  and  beside  it  another  full  of  serous 
fluid,  and  found  there  was  no  difference  between  the  respective  shadows 
cast  on  the  screen.     (See  Chapter  I,  page  6.) 

If  we  examine  the  chest  with  the  fluorescent  screen,  we  can  never 
fail  to  recognize  an  abnormal  condition  of  the  thorax  if  a  pleuritic  effu- 
sion or  an  empyema  be  present. 

Methods  of  Examination.  —  In  making  X-ray  examinations  of  a 
patient  suffering  from  pleurisy  with  effusion,  the  outline  of  the  dark 
area  as  well  as  the  other  outUnes  in  the  thorax  may  be  seen  to  change 
in  most  cases  when  the  patient  changes  his  position.  Therefore  the 
patient  should  be  examined  when  he  is  lying  on  his  back  and  when  he 
is  sitting  up,  and  the  outlines  thus  seen  be  traced  and  compared.  (See 
Appendix.)  He  should  also  be  examined  both  when  lying  on  his  right 
side  and  on  his  left  side,  the  tube  being  on  a  level  with  his  thorax,  and 
the  light  going  through  the  chest  horizontally  when  it  is  desired  to  dis- 
tinguish, as  far  as  may  be,  between  a  possible  fluid  in  the  chest  and  other 
conditions,  such  as  a  dense  lung.  The  position  of  the  heart  and  parts 
above  it  should  be  noted,  and  the  obliteration  of  the  Unes  of  the  dia- 
phragm, or  the  movement  of  this  muscle,  if  any  part  of  it  can  be  seen. 

Comparison  of  Fluorescent  Screen  and  X-Ray  Photograph.  —  The 
screen  is  better  than  the  photograph  for  examining  cases  of  pleurisy. 

The  appearances  seen  on  the  fluorescent  screen  in  pleurisy  with 
effusion  are  still  further  illustrated  by  the  following  notes  of  cases,  and 
by  the  accompanying  figures  made  from  the  tracings  which  I  first  drew 
on  the  skin  of  the  patient,  reduced  one-half  and  transferred  to  the 
blanks  described  on  pages  79-80.  The  cuts  are  reduced  still  further, 
so  that  they  are  about  one-third  life  size. 

Case  I.  Patrick  McM.,  twenty-one  years  of  age,  entered  the  Bos- 
ton City  Hospital  August  29,  1896.     Service  of  Dr.  Sears. 

PJiysical  Examination.  —  Lungs  :  dulness  in  the  right  front  from  apex 
to  fourth  rib ;  flatness  at  fifth  intercostal  space ;  in  axilla,  dulness  from 
level  of  fourth  rib  downward  and  in  right  back  from  one  inch  above 
spine  of  scapula,  becoming  flatness  at  angle  of  scapula ;    respiration, 


2o6     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


tactile  fremitus,  and  voice  sounds  diminished  from  above  downward. 
Heart :  right  border  not  determined  ;  left  border  just  inside  nipple  line  ; 
apex  beat  in  fifth  space ;  action  regular ;  no  murmurs. 


Name 

Address 

Diagnosis 


'Ui/  ^^ 


Age 
Occupation 


Date 


Fig.  129.  Patrick  McM.  Pleurisy  with  effusion.  X-ray  examination  with  screen.  Darkened 
area  on  right  side;  no  ribs  and  no  outline  of  diaphragm  could  be  seen  on  this  side.  Heart  displaced 
to  left  (not  shown  in  cut,  nor  are  the  diaphragm  lines  on  the  left  side).     (Cut  one-third  life  size.) 

X-Ray  Examination  luith  Screen.  —  I  found  the  contrast  between  the 
two  sides  of  the  chest  was  very  marked.  On  the  right  side,  below  the 
third  rib,  there  was  no  light,  or  only  as  much  as  comes  through  the  liver 
ordinarily,  and  this  much-darkened  area  extended  to  the  level  of  the  upper 
border  of  the  third  rib ;  even  above  this  point  there  was  less  light  than 
on  the  opposite  side.     No  ribs  and  no  outline  or  movement  of  the  dia- 


PLEURISY   WITH    EFFUSION.     EMPYEMA  207 

phragm  could  be  seen  on  the  right  side.  (See  Fig.  129,  Patrick  McM.) 
The  heart  was  displaced  to  the  left. 

September  6.  Twenty-five  ounces  of  fluid  were  withdrawn  from  the 
patient's  chest. 

At  a  second  AV<?j  examination  the  upper  half  of  the  chest  was 
found  to  be  much  clearer  than  at  the  previous  one,  though  not  as  clear 
as  on  the  opposite  side.  The  ribs  could  be  seen  on  both  sides,  but  the 
outline  of  the  diaphragm  was  only  faintly  visible  on  the  right  side.  The 
heart  was  still  somewhat  displaced  to  the  left. 

Case  II.  Mary  E.  H.,  thirteen  years  old,  entered  the  hospital 
August  29,  1896.  A  patient  of  Dr.  John  L.  Ames.  Diagnosis:  acute 
miliary  tuberculosis  and  meningitis. 

It  was  a  question  whether  or  not  fluid  was  present  in  this  patient's 
chest.  Thoracentesis  had  been  performed  by  Dr.  Ames,  but  no  fluid 
was  obtained. 

Physical  Examinatio7i.  —  Lungs  :  dulness  in  right  front  from  clavicle, 
becoming  flatness  at  fourth  rib ;  in  axillary  space,  dulness  throughout, 
becoming  flatness  at  level  of  fourth  rib.  In  the  back,  on  right  side,  dul- 
ness from  spine  of  scapula,  becoming  flatness  one  inch  above  angle  of 
scapula.  Tactile  fremitus  diminished  over  dull  area,  absent  over  flat 
area.  Bronchial  respiration  over  lower  half  of  chest ;  in  the  upper  half 
respiration  exaggerated.  Respiration  also  exaggerated  in  the  left  lung. 
Heart :  right  border  not  determined  ;  left  border  9.25  centimetres  to  the 
left  of  the  median  line  ;  apex  in  fifth  space. 

September  3.     Twenty-five  ounces  of  clear  serous  fluid  withdrawn. 

September  4.  Physical  Examination.  —  In  right  front,  dulness  from 
fourth  rib,  and  from  same  level  in  axilla  ;  in  right  back,  from  just  below 
angle  of  scapula  ;  respiration  heard  to  base  ;  voice  sounds  and  tactile 
fremitus  absent.  From  third  to  fourth  rib  in  front,  bronchial  respira- 
tion, with  rales. 

September  4.  My  X-Ray  Examination  zvith  Screen.  —  As  indicated  in 
the  cut  (Fig.  130),  the  right  side  of  the  chest  was  divided  into  a  dark 
and  a  light  area,  the  line  between  these  two  running  from  the  point 
where  the  cartilage  of  the  sixth  rib  joins  the  sternum  in  a  direction 
upward  and  outward  towards  the  lower  end  of  the  right  clavicle.  Above 
this  line  the  pulmonary  area  was  darker  than  the  corresponding  area  of 
the  left  lung,  but  much  lighter  than  the  area  below  it  on  the  right  side. 
Later,  the  chest  was  again  tapped  and  fluid  withdrawn. 

It   will   be   noticed   that   in    Figs.    129,    130,    the    shadow    against 


2o8    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


the  thoracic  wall  is  darker  and  higher  up  than  that  near  the 
sternum.  One  reason,  certainly,  for  this  fact  is  the  following:  The 
fluid  naturally  rises  between  the  costal  and  pulmonary  pleurse,  and 
therefore  if  the  screen  were  on  the  front  of  the  chest,  with  the  tube 


Name 

Address 

Diagnosis 


^a.^y  S  M 


Age 
Occ7ipation 


Date 


ac<. 


7- 


^ol.j^Y-  ^'^- 


!•  IG.  130.  Mary  E.  H.  Pleurisy  with  effusion.  X-ray  examination  with  screen  September 
4tli.  Darkened  area  on  right  side,  running  from  junction  of  cartilage  with  sixth  rib  to  outer  end  of  right 
clavicle.     (Cut  one-third  life  size.) 


behind  the  patient,  the  rays  falling  near  the  costal  wall  of  the  thorax 
must  pass  through  a  layer  of  fluid  that  is  as  thick  as  the  chest  is  deep, 
whereas  in  the  neighborhood  of  the  sternum  the  rays  traverse  a  layer 
of  fluid  at  the  back  and  front  of  the  chest,  respectively,  which  is  sepa- 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


209 


rated  by  the  transparent  lung,  and  therefore  not  so  much  obstruction  is 
offered  to  the  rays  in  the  latter  case  as  in  the  former.  Likewise  the 
shadow  is  very  dark  below  the  lung,  as  there  also  the  rays  are  obstructed 
by  an  unbroken  layer  of  fluid.  The  upper  line  of  the  darkest  part  of 
the  shadow  reaching  from  the  outer  wall  of  the  thorax  to  the  sternum, 
therefore,  is  curved,  unless  the  whole  side  of  the  thorax  is  perfectly 
dark  as  in  Fig.  128. 

Case  III.  Thomas  R.,  thirty-eight  years  old,  entered  my  service 
at  the  hospital  March  9,  1897.     Diagnosis  :  pleurisy  with  effusion. 

History. —  Malaria  eighteen  months  before.      Hard  drinker. 

Present  Illness.  —  Pain  in  left  side  for  fourteen  days,  worse  on 
breathing  ;  cough,  with  yellow  sputum  ;  headache  ;  cannot  lie  on  left 
side  ;  unable  to  sleep  on  account  of  pain. 

Physical  Examination.  —  Good  resonance  and  respiration  over  right 
lung.  Left  lung  :  in  front  breathing  somewhat  exaggerated  over  left 
upper  chest ;  slight  hyper-resonance ;  breathing  diminished  ;  marked 
friction  rub.  Beginning  at  third  rib,  dulness,  becoming  flatness  at 
fifth  rib,  and  extending  into  axilla.  Over  this  area  breathing  very 
faint,  almost  absent.  Vocal  and  tactile  fremitus  much  diminished.  In 
left  back,  percussion  over  upper  third  lacking,  with  increased  tactile 
fremitus  and  diminished  breathing  ;  dulness  beginning  two  centimetres 
below  angle  of  scapula,  flatness  from  angle  of  scapula  to  base.  Over 
this  area  breathing  much  diminished,  with  diminished  vocal  and  tactile 
fremitus. 

March  12.  X-Ray  Examination  with  Screen. —  First  and  second  ribs 
seen  faintly.  The  whole  of  the  left  chest  dark.  Heart  displaced  to  the 
right  (Fig.  131). 

March  17.  Ten  ounces  of  fluid  withdrawn.  Needle  inserted  in  the 
back,  below  angle  of  scapula. 

March  29.     Sixteen  ounces  of  fluid  withdrawn. 

April  26.  Physical  Examination.  —  Dulness  in  left  back  from 
angle  of  scapula  to  base,  also  in  left  axilla ;  dulness  in  front  from 
fifth  rib  to  base.  Breathing  somewhat  diminished ;  voice  sounds 
distant ;  diminished  tactile  fremitus. 

April  26.  Third  X-Ray  Examination  ivith  Screen.  —  Right  side 
perfectly  clear.  On  the  left  side  the  first,  second,  third,  and  fourth  ribs 
seen  ;  no  outline  of  the  left  border  of  the  heart.  Heart  still  displaced 
to  the  right  (Fig.  132). 

May  II.     Discharged. 


2IO    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


Patient  again  entered  the  hospital  May  31,  1897. 
Physical  Examination.  —  Heart :  area,  action,  and  sounds    normal. 
Lungs :  in  front  dulness  in  left  chest  and  axilla  below  level  of  fifth  rib, 


Name 

Address 

Dias^nosis 


y/i/yv^xy<^a^  /^  . 


Occupation 


Date 


Fk;.  131.  Thomas  R.  March  12,  1897.  Pleurisy  with  effusion.  First  X-ray  examination  with 
screen.  Whole  of  left  chest  dark;  first  and  second  ribs  seen  faintly;  heart  displaced  to  right.  (Cur 
one-third  life  size.) 


with  diminished  breathing  and  voice  sounds ;  tactile  fremitus  much 
diminished  ;  in  the  left  back  the  same  signs,  most  marked  from  below 
angle  of  scapula  to  base;  at  base,  flatness  by  percussion;  respiratory 
murmur  absent. 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


21 1 


June  5.     X-Ray  Examination  with  Screen.  —  On  the  left  side  the  ribs 
could  be  seen  from  the  first  to  the  fourth  rib,  though  less  clearly  than  on 


Name 


y^^^uiA^a^  ^\ 


Address 
Diagnosis 


Age 
Occupaltan 


Date 


,^Y^A>C^   Z6 


Vol. 


Page 


\  Fig.  132.    Thomas  R.     April  26.    Third  X-ray  examination  with  screen.     Right  side  perfectly 

I  clear;  first,  second,  and  third  ribs  seen  on  left  side;  no  outline  of  left  border  of  heart  visible;  heart 
I  still  displaced  to  right.     (Cut  one-third  life  size.) 

I 

!  the  right  side.  A  portion  of  the  left  border  of  the  heart  could  be  made 
;  out.  No  diaphragm  lines  were  seen  on  the  left  side,  even  in  full  inspi- 
I  ration.     The  upper  portion  of  the  fluid,  though  of  course  not  well  defined, 


212     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


was  rather  more  so  while  the  patient  was  sitting  up  than  while  lying 
down.     (See  Fig.  133.) 

June  8.     The  physical  signs  were  the  same  as  on  May  31. 


Name 

.Address 

Diagnosis 


^/^^f-l^^^dLJ     /\.  Age  Dateyf^'^^'^^    ^ 

Occupation  ^       Vol.  Page 


-^ 


Fig.  133.  Thomas  R.  June  5.  Fifth  X-ray  examination  with  screen.  Left  side,  ribs  seen  from 
first  to  fourth  rib,  though  less  clearly  than  on  right  side.  Portion  of  left  border  of  heart  visible ;  no 
diaphragm  lines  seen  on  left  side,  even  in  full  inspiration.  Excursion  of  diaphragm  on  right  side. 
7.5  centimetres  (3  inches).      (Cut  one-third  life  size.) 

Five  X-ray  examinations  of  this  patient  were  made,  as  follows : 
March  12,  April  7,  April  26,  May  10,  June  5. 

The  records  of  those  made  on  March  12,  April  26,  and  June  5,  only, 
are  given  in  the  accompanying  cuts. 


PLEURISY   WITH    EFFUSION.     EMPYEMA  213 

These  three  cases,  Patrick  McM.,  Mary  E.  H.,  and  Thomas  R.  show 
that  the  level  of  the  fluid  in  pleurisy  is  not  horizontal,  as  we  shall  see  later 
that  it  is  in  pneumohydrothorax  ;  that  the  heart  is  displaced,  and  that 
one  border  may  be  easily  seen.  The  last  case  also  indicates  the  way  in 
which  the  appearances  seen  in  the  chest  change  as  the  fluid  is  absorbed. 

The  X-ray  examination  may  be  of  assistance  in  making  the  diagno- 
sis, and  in  directing  the  physician  where  to  insert  the  needle  when  the 
chest  is  to  be  tapped. 

Untrustworthiness  of  Percussion  in  determining  the  Presence  of  Fluid 
by  Means  of  a  Displaced  Heart.  —  The  displacement  of  the  heart,  caused 
by  fluid  in  the  chest,  as  shown  by  the  tracing  (see  Fig.  134),  may  be  very 
marked  and  still  not  be  detected  at  all  by  percussion,  or  if  detected,  its 
extent  may  not  be  accurately  estimated.  The  displacement  of  the  heart 
to  the  right  is  often  less  readily  recognized  by  this  means  than  that  to  the 
left.  It  is  obvious,  therefore,  that  failure  by  this  method  to  recognize  the 
presence  of  fluid  by  means  of  a  displaced  heart  in  those  cases  in  which 
the  physical  signs  do  not  point  clearly  to  a  pleuritic  effusion,  and  the 
physician  has  called  percussion  to  his  aid,  does  not  justify  him  in  assuming 
that  no  displacement  and  fluid  are  present.  The  X-ray  examination  is  the 
more  trustworthy  test  of  a  displaced  heart  in  pleurisy  with  effusion  than 
percussion.  The  following  cases  illustrate  this  point.  The  first  trac- 
ing shows  how  marked  the  discrepancy  may  sometimes  be  between 
the  border  of  the  heart,  as  determined  by  percussion,  and  its  actual 
border,  as  seen  by  an  X-ray  examination,  and  that  the  X-rays  give  more 
direct  and  definite  signs  of  fluid  in  the  chest  than  auscultation  and  per- 
cussion in  some  patients. 

Case  I.  Constantine  D.,  twenty-four  years  of  age,  entered  my 
service  at  the  Boston  City  Hospital  January  20,  1899. 

History.  —  In  bed  for  four  weeks  with  malaria ;  cough,  with  consid- 
erable expectoration,  and  pain  in  the  left  side  on  deep  inspiration; 
diarrhoea  for  one  week;  pulse  regular  and  of  fair  strength;  heart  not 
displaced. 

In  the  lungs,  at  the  right  apex,  there  was  slight  dulness  and  harsh 
breathing: ;  numerous  sonorous  and  sibilant  rales  in  both  chests,  back 
and  front ;  slight  increase  in  tactile  fremitus  at  the  right  apex. 

January  22.  Physical  examination.  —  In  the  left  back,  just  below 
spine  of  scapula,  there  was  an  area  of  the  size  of  the  palm  of  the  hand 
where  there  was  dulness  and  harsh  breathing,  with  marked  increase  in 
voice  sounds,  but  no  increase  in  tactile  fremitus. 


214    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

January  23.  Physical  Examination.  —  In  the  left  back,  below  the 
spine  of  scapula,  there  is  still  harsh  breathing,  with  increase  in  voice 
sounds  and  absence  of  tactile  fremitus. 

An  X-ray  examination  with  screen  on  this  same  date  showed  that  the 
left  chest  was  dark  throughout ;   also  that  the  heart  was  displaced  so 


Cona/antine  D 
Pfeanfic  Pt/'c/^ian 
Le/rJ,ck 
Jan  23 c^ 


Fig.  134.  Constantine  D.  January  23.  Cut  of  X-ray  tracing.  Pleuritic  effusion  on  left  side;  heart 
displaced  to  right.  Dotted  line  indicates  position  of  right  border  as  determined  by  percussion ;  full 
curved  line  to  the  right  of  it,  the  position  of  the  right  side  of  the  heart  as  determined  by  the  fluores- 
cent screen.  The  broken  and  full  lines  below  the  right  nipple  show  the  position  of  the  right  half  of 
the  diaphragm  in  expiration  and  full  inspiration  respectively.     (Cut  one-third  life  size.) 


that  its  right  border  was  nearly  7  centimetres  to  the  right  of  the 
median  line.  This  condition  showed  that  there  probably  was  fluid  in  the 
chest.     (See  Fig.  134.) 

The  full  line  indicates  the  right  border  of  the  heart  as  seen  by  X-ray 
examination,  and  the  dotted  line  this  border  as  found  by  percussion. 
This  case  is  also  given  in  the  chapter  on  the  Heart. 

On  January  25  I  drew  out  56  ounces  of  serous  fluid  from  the  left 
chest. 

Later  this  patient  developed  pneumohydrothorax. 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


215 


In  the  following  case  the  X-rays  show  that  the  heart  was  pushed 
farther  to  the  left  than  percussion  indicated,  and  that  the  parts  above  the 
heart  were  also  pushed  to  the  left,  and  that  their  shadow  had  a  strong 
slant  in  this  direction  instead  of  being  vertical  as  in  health  :  — 

Case  I.  James  L.,  sixty-two  years  old,  entered  my  service  at  the 
hospital  February  9,  1899.     Diagnosis:    pleurisy  with  effusion. 

History.  —  Shortness  of  breath  for  nine  months. 


Ja/jvco  L 

P/eurj/7c  n/fii^jon 


Fig.  135.  James  L.  February  13.  Cut  of  X-ray  tracing.  Pleuritic  effusion  on  right  side. 
Heart  and  contents  of  mediastinum  displaced  to  left.  Diaphragm  on  left  side  pulled  down  and 
excursion  limited,  as  indicated  by  broken  line  and  full  line  below  it.     (Cut  one-third  life  size.) 


Present  Illness.  —  Some  cough ;  excessive  shortness  of  breath  and 
weakness. 

Physical  Examination.  —  Arteries  thickened  and  tortuous.  Pulse 
irregular  and  weak.  Heart :  right  border  just  to  right  of  right  sternal 
border ;  left  border  in  nipple  line ;  apex  in  fifth  space  in  nipple  line ; 
action  regular  ;  sounds  weak  and  distant ;  no  murmurs  detected.  Lungs  : 
resonance  good  over  right  lung  to  third  space  in  front,  and  to  spine  of 
scapula  behind,  below  which  is  flatness.  Respiration  over  right  chest 
above  flat  area,  and  over  left  chest,  is  harsh,  with  prolonged  wheezy  and 


2i6    THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

sonorous  expiration.  Respiration  of  the  same  character  is  heard  over 
area  of  flatness,  but  much  diminished. 

February  1 3.  X-ray  examination  with  screen  showed  that  the  heart 
was  displaced  to  the  left,  and  the  line  of  the  blood  vessels  above  the 
heart  were  also  displaced  to  the  left,  as  indicated  by  the  oblique  line. 
(See  Fig.  135.) 

Encysted  Pleurisy.  —  In  cases  of  encysted  pleurisy  the  physical  signs 
may  be  difificult  to  interpret,  and  the  real  condition  present  may  be  more 
clearly  indicated  by  an  X-ray  examination  than  by  any  other  method. 
The  following  case  illustrates  this  point :  — 

Case  I.  William  T.,  colored,  forty  years  of  age,  entered  my  service 
at  the  hospital  March  4,  1897.      Diagnosis:  pleurisy  with  effusion. 

Present  Illness.  —  Cough  for  four  weeks  ;  vomiting  ;  no  pain  ;  some 
shortness  of  breath  due  to  abdominal  distension. 

Physical  Exaviinations.  —  The  lungs  showed  good  resonance  every- 
where except  for  slight  dulness  in  the  left  axilla,  where  respiration  is 
diminished. 

March  17.  X-ray  examination  ivith  screen  (Fig.  136)  showed  a  dark 
area  extending  from  the  third  to  the  ninth  rib,  as  indicated  in  the  cut. 
The  excursion  of  the  diaphragm  on  the  left  side  was  2.5  centimetres, 
and  on  the  right  side  4.5  centimetres. 

On  March  18  a  needle  was  inserted  into  the  middle  of  the  dark 
area  on  the  left  side  and  a  syringeful  of  cloudy,  yellowish  fluid  with- 
drawn. An  attempt  had  previously  been  made  to  obtain  fluid,  but  was 
unsuccessful. 

MarcJi  19.  A  second  X-ray  examination  with  screen  showed  the 
same  condition  as  had  obtained  on  March  17. 

The  patient  died  on  April  6. 

An  autopsy  was  made  by  Dr.  F.  B.  Mallory,  who  found  on  the  outer 
side  of  the  left  chest,  corresponding  to  the  dark  area  seen  by  X-ray 
examination,  an  old  encysted  pleurisy  with  walls  1.25  centimetres  thick. 

The  autopsy  record  was  as  follows :  "  The  pleura  over  the  lateral 
and  posterior  aspect  of  the  left  lung,  and  over  the  whole  lower  lobe,  and 
the  lower  half  of  the  upper  lobe,  was  enormously  thickened  and  could 
be  freed  v/ith  diflficulty  from  the  costal  pleura  by  the  use  of  the  knife. 
The  costal  layers  of  pleura  vary  in  thickness  from  2  to  3  centi- 
metres; the  parietal  pleura  from  i  to  1.5  centimetres  in  thick- 
ness. Between  the  two  was  a  mass  of  broken-down  yellowish  white 
softened  material.     The  thickened  pleura  consisted  of  an  external  and 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


217 


extremely  dense  layer  of  fibrinous  tissue.     The  inner  layer  was  soft  and 
more  or  less  gelatinous.     This  was  a  mass  of  old  organized  pleurisy." 


Name 

Address 

Diagnosis 


Occupation  Vol.  Po^ge 


Fig.  136.  William  T.  March  17,  1897.  X-ray  examination  with  screen.  Encysted-  pleurisy. 
Darkened  area  from  third  to  ninth  rib.  Diaphragm  lines  not  shown.  Excursion  4.5  centimetres  on 
right  side  ;  2.5  on  left  side.     (Cut  one-third  life  size.) 

This  case  is  of  interest,  as  showing  how  much  more  definite  informa- 
tion was  obtained  by  the  X-ray  examination  than  had  been  yielded  by 
auscultation  and  percussion. 


2i8     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Interlobar  Empyema  or  Pleurisy.  —  Fluid  may  not  only  be  encysted 
in  the  pleura  against  the  thoracic  wall,  but  may  also  be  enclosed  in  the 
pleural  membrane  between  the  lobes  of  a  lung,  and  such  a  collection  of 
fluid  would  cast  a  shadow  if  the  lung  surrounding  it  were  at  all  clear. 
Physical  signs  would  not  give  as  direct  information  as  the  X-ray 
examination. 

Diaphragmatic  Pleurisy.  —  I  have  never  examined  a  case  of  dia- 
phragmatic pleurisy  with  the  X-rays,  but  they  would  probably  be  of 
service  here  also. 

Pleurisy  with  Effusion  and  Emphysema.  —  In  pleurisy  with  effusion 
complicated  with  emphysema  the  latter  condition  is  not  always  recog- 
nized by  the  physical  examination,  but  may  be  indicated  by  the  X-ray 
examination.     The  following  case  is  illustrative  :  — 

Case  I.  John  S.,  forty-two  years  old,  entered  my  service  at  the 
hospital  April  6,  1898.  Diagnosis:  pleurisy  with  effusion  on  the  right 
side. 

The  amount  of  dyspnoea  obtaining  was  unusual  for  the  quantity  of 
fluid  apparently  present  in  the  chest.  On  April  6  he  was  aspirated  and 
56  ounces  of  fluid  were  withdrawn. 

X-ray  exantinatioji  with  screen  indicated  an  emphysema  of  the  left 
lung,  which  accounted  perhaps  for  the  unusual  dyspnoea.  This  emphy- 
sema had  not  been  recognized  by  the  physical  examination.  The 
amount  of  fluid  in  the  chest  would  probably  have  given  the  patient  com- 
paratively little  trouble  had  there  been  no  emphysema.  The  X-ray 
examination,  then,  by  demonstrating  the  disability  under  which  the  lung 
was  suffering,  led  me,  on  account  of  the  dyspnoea,  to  tap  the  chest  and 
draw  off  the  fluid  again  two  days  later,  at  which  time  42  ounces  were 
withdrawn. 

Pleurisy  with  Effusion  and  Pneumonia.  —  Dougald  M.,  eighteen 
years  old,  entered  my  service  at  the  hospital  December  i,  1899.  Diag- 
nosis :  pleurisy  with  effusion  and  pneumonia. 

History.  —  Patient  caught  severe  cold  ;  had  chill,  with  dyspnoea  ;  pain 
in  the  left  chest;  cough  with  rusty  expectoration;  temperature  104, 
respirations  30. 

Physical  Examination.  — Heart :  right  border  3.7  centimetres  to  the 
right,  and  left  border  8.25  centimetres  to  the  left  of  the  median  line  ; 
action  regular  ;  slight  presystolic  murmur  at  apex,  not  transmitted,  but 
heard  in  fifth  interspace  where  apex  is  best  located.  Lungs  :  at  right 
apex,  above  clavicle,  prolonged  respiratory  murmur ;  whole  right  back 


PLEURISY  WITH   EFFUSION.     EMPYEMA 


219 


from  apex  to  just  above  angle  of  scapula  is  more  dull  than  left;  above 
the  spine  there  is  broncho-vesicular  respiration,  with  increased  tactile 
fremitus.  Left  chest  moves  apparently  more  than  right  in  respiration, 
though  seat  of  chief  pain  is  in  right  side ;  percussion  note  not  good  any- 
where ;  left  side  in  front  slightly  more  dull  than  right,  except  at  apex, 
where  note  is  less  high-pitched  than  on  right ;  respiratory  murmur  not 


Doacjofcl  M  Dec  9 


Pnenmowo  /  P/ean/jc  Z'f/o 
on  LeffJic/e 


Fig.  137.  Dougald  M.  December  9,  1899.  First  X-ray  tracing.  Pneumonia  on  left  side 
and  at  right  apex ;  pleurisy  with  effusion  on  left  side ;  heart  much  displaced  to  right.  Dotted  line 
shows  right  border  of  heart  by  percussion  ;  full  line,  by  X-rays.     (Cut  one-third  life  size.) 

good  anywhere  ;  tactile  fremitus  about  the  same  on  both  sides.  A  few 
rales  heard  in  left  back. 

December  3.      Diminished  respiratory  murmur  heard  in  left  back. 

December  5.  Tactile  fremitus  increased  over  left  scapular  region 
and  increased  voice  sounds.     No  rales  heard. 

December  8.  Over  lower  left  chest,  front  and  back,  is  diminished 
tactile  fremitus,  distant  but  bronchial  respiration,  and  suggestion  of 
aegophonic  voice ;  a  few  medium  moist  rales  in  middle  front  and  back  ; 


2  20     THE    ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 

resonance  in  upper  left  chest  tympano-vesicular  with  increased  tactile 
fremitus. 

December  (^,  1899.  X-Ray  Examination  with  Screen.  —  Left  chest 
(see  Fig.  137)  dark  throughout,  no  diaphragm  lines  seen,  and  the  heart 
somewhat  displaced  to  the  right  and  also  enlarged,  especially  on  the  right 
side,  as  it  usually  is  in  pneumonia.  These  appearances  suggest  a  pleu- 
ritic effusion  in  the  left  chest ;  and  the  extension  of  the  darkened  area  to 
the  apex  and  the  enlarged  heart,  in  connection  with  the  physical  signs, 
indicate  that  there  is  also  a  pneumonic  process  on  this  side.  If  the 
quantity  of  fluid  present  were  sufficient  to  darken  the  apex,  greater  dis- 
placement of  the  heart  to  the  right  would  be  looked  for  than  obtains. 
The  right  apex  is  also  darkened  and  the  excursion  of  the  diaphragm  on 
the  right  side  shortened.  As  the  patient  has  pneumonia,  there  is  no 
present  reason  to  consider  the  appearances  on  this  side  as  due  to  tuber- 
culosis, although  the  X-ray  signs  on  this  side,  if  taken  by  themselves, 
might  be  caused  either  by  a  pneumonia  at  the  right  apex  or  by  a  tubercu- 
lous process. 

December  10.  The  left  chest  was  aspirated  and  32  ounces  of  clear 
serous  fluid  was  siphoned  off.  After  aspiration  the  physical  signs 
were  as  follows  :  dulness  below  sixth  rib  in  front,  and  below  a  line  half- 
way between  spine  and  angle  of  scapula  behind,  on  the  left  side  ;  tac- 
tile fremitus  absent ;  respiratory  sounds  distinctly  bronchial  and  voice 
sounds  asgophonic  ;  resonance  in  upper  left  chest  much  less  tympanitic, 
and  tactile  fremitus  not  so  much  increased. 

December  14.  Dulness  quite  marked  at  the  right  apex,  with  pro- 
longed expiratory  murmur. 

December  24.  Fluid  seems  to  have  disappeared  ;  respiratory  murmur 
very  slight  at  base  behind  ;  signs  present  at  right  apex. 

January  i ,  1 900.  Second  X-Ray  Examination  toith  Screen  ( Fig.  1 38). — 
There  is  no  fluid  in  the  lower  part  of  the  left  chest,  as  the  diaphragm 
on  this  side  is  clearly  seen  in  inspiration,  but  much  of  the  left  side  is 
still  dark  owing  to  the  pneumonia.  The  darkness  is  most  marked 
below,  and  in  this  portion  of  the  chest  is  probably  due  to  pneumonia  and 
a  thickened  pleura.  The  heart  is  still  enlarged.  On  the  right  side  the 
improvement  is  very  marked.  The  apex  is  much  lighter  and  the  excur- 
sion of  the  diaphragm  greater  than  at  the  X-ray  examination  made  three 
weeks  before. 

The  special  point  of  interest  in  this  case  is  the  fact  that  the  physical 
signs  in  the  lower  part  of  the  left  chest,  when  taken  in  connection  with 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


221 


the  knowledge  that  the  patient  had  had  a  pleuritic  effusion,  indicated, 
although  fluid  had  been  recently  drawn  from  the  left  pleural  cavity,  that 
some  was  still  remaining  there.  The  X-ray  examination  made  at  this 
time,  however,  showed  that  no  fluid  was  present.  The  physical  signs  in 
the  left  chest  at  the  base,  which  suggested  that  some  fluid  still  remained, 
were  probably  due  to  the  density  persisting  in  the  lung  from  the  pneu- 
monic process.    This  same  X-ray  examination  also  showed  that  the  right 


Q 


j^/ter  Pneamo/ua  J^  P/eiinhc  njjaj^joj] 
Jon  M' 


Fig.  138.  Dougald  M.  January  i,  1900.  Second  X-ray  tracing.  (Compare  with  first  tracing 
of  this  patient,  Fig.  137).  Improvement  at  right  apex  and  increase  in  excursion  of  diaphragm  on 
that  side.  On  the  left  side  the  lung  is  less  dense  and  there  is  no  pleuritic  effusion,  as  the  diaphragm 
lines  can  now  be  well  seen.     (Cut  one-third  life  size.) 

apex  had  improved  very  much,  therefore  that  the  process  was  probably 
not  tuberculous.  Six  examinations  of  the  sputa  were  made  and  no  bacilli 
found.  The  patient  had  evidently  had  a  pleurisy  and  pneumonia  on  the 
left  side  and  a  pneumonia  at  the  right  apex.  It  is  a  great  satisfaction 
in  such  a  case  as  this  to  see  the  improvement  in  both  lungs,  and  to  be 
assured  that  there  is  no  fluid  in  the  left  chest  and  that  the  patient  is 
making  excellent  progress. 


22  2      THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

Pleurisy  with  Effusion  and  Pulmonary  Tuberculosis.  —  Pleurisy  with 
effusion  and  tuberculosis,  as  is  well  known,  are  not  infrequently  associ- 
ated. If  by  means  of  the  fluorescent  screen  the  physician  examines  at 
intervals  a  patient  suffering  with  a  pleuritic  effusion,  he  will  sometimes 
find  that,  although  the  chest  becomes  clearer  in  its  lower  portion,  as  the 
fluid  is  absorbed,  it  remains  dark  above,  and  that  an  increasing  light  area 
may  be  seen  in  some  patients  between  the  upper  and  lower  part  of  the 
chest  as  the  fluid  subsides.  In  such  cases  the  physician  should  look  for 
tuberculosis.  The  signs  of  tuberculosis  at  the  apex  of  the  lung  become 
more  and  more  apparent  as  the  liquid  disappears  on  that  side  ;  they 
have  been  at  first  obscured  by  the  fluid.  Or  the  physician,  while  exam- 
ining a  patient  with  pleurisy  on  one  side,  may  observe  that  the  apex  of 
the  lung  on  the  other  side  is  also  dark,  and  thus  his  attention  may  be 
drawn  to  an  early  tuberculosis. 

While  examining  some  cases  of  pleurisy  with  effusion  ^  with  the 
fluorescent  screen,  I  have  found  indications  of  tuberculosis  in  the  lung 
which  was  not  previously  suspected.  The  consideration  of  three  cases 
will  be  sufficient  to  illustrate  the  importance  of  examining  our  patients 
by  the  X-rays,  not  only  at  the  beginning,  but  also  during  the  subsidence 
of  the  fluid ;  if  these  examinations  are  not  made,  an  early  tuberculosis 
may  be  overlooked. 

Case  I.  Mary  F.,  nineteen  years  old,  entered  my  service  at  the 
hospital  on  April  8,  1897.     Diagnosis:  pleurisy  with  effusion. 

Present  Illness.  —  Sharp  pain  in  the  left  side  on  inspiration,  which 
began  seven  weeks  ago ;  breathing  short  and  quick  ;  slight  cough  ;  for 
two  weeks  has  had  sense  of  oppression  in  left  chest. 

Physical  Examination.  —  Heart  not  displaced  to  the  right.  Lungs  : 
tympany  over  left  upper  chest,  with  increased  tactile  fremitus  ;  dulness 
beginning  at  fourth  rib,  becoming  flatness  in  axilla ;  above  fourth  rib 
respiration  rather  harsh ;  below  fourth  rib  and  in  axilla  breathing 
diminished  and  almost  absent  at  base,  with  voice  sounds  distant ; 
vocal  and  tactile  fremitus  much  diminished.  In  left  back  good 
resonance  to  middle  of  scapula;  dulness  beginning  2.5  centimetres 
above  angle  of  scapula,  with  flatness  at  the  base  ;  vocal  and  tactile 
fremitus  diminished,  with  distant  breathing.  In  right  front  slight 
dulness  at  apex,  with  normal  respiration  ;  tactile  fremitus  increased  ; 
good  resonance  and  respiration  in  right  back. 

1  "A  Study  of  the  Adaptation  of  the  X-Fays  to  Medical  Practice,"  Medical  and  Surgical 
Reports  of  the  Boston  City  Hospital,  January,  1897. 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


223 


April  10.  X-ray  examination  with  screen  showed  that  the  heart 
was  much  displaced  to  the  right  and  that  the  left  chest  was  dark,  the 
darkened  area  extending  throughout  the  apex  of  the  lung  (Fig.  139). 


Name    'Tu^^^ 

Address 

Diagnosis 


?■  ^^,/f  o,^  .j4f.^/<i.9/. 


Occupation 


Vol. 


Page 


Fig.  139.  Mary  F.  April  lo,  1897.  First  X-ray  examination  with  screen.  Pleurisy  with  effusion 
on  left  side ;  heart  displaced  to  right.  Excursion  of  diaphragm  4.5  centimetres,  shortened  on  right 
side.     (Cut  one-third  life  size.) 


After  the  X-ray  examination  was  made,  17  ounces  of  slightly  bloody 
fluid  were  withdrawn  from  the  left  chest. 

May  12.  Second  X-Ray  Examination  ivith  Screen.  —  A  light  area 
between  the  upper  and  lower  portion  of  the  lung  showed  that  the  fluid 


224     THE    ROENTGEN    RAYS   IN    iMEDlCINE   AND   SURGERY 


had  subsided.     The  apex  of  the  lung  still  remaining  dark  suggested  the 
presence  of  tuberculosis.     (See  Fig.  140.) 

The  patient  was  given   i   milligramme  of  tuberculin  and  there  was 
a  well-marked  reaction. 


Name  j/ljiaJlM      Y. 

.Address  / 

Diagnosis 


Age/<f       Date    Tk^y/Z  ^/. 

cupation  Vol.  Page 


Occupation 


Fig.  140.  Mary  F.  May  12.  Second  X-ray  examination  with  screen.  Less  effusion  in  left 
chest.  Darkened  left  apex  from  tuberculosis.  Light  area  seen  between  the  effusion  and  darkened 
apex.  Excursion  of  diaphragm  on  right  side  7  centimetres  greater  than  at  first  examination.  (Cut 
one-third  life  size.) 


May  18.  Third  X-Ray  Examination  witJi  Screen.  —  The  light  area 
noted  on  May  12  had  become  so  broad  that  a  part  of  the  left  border  of  the 
heart  could  be  seen.  This  increase  in  the  light  area  showed  a  further 
subsidence  of  the  fluid.     The  darkened  apex  still  persisted  (Fig.  141). 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


225 


The  next  case,  John  J.  L.,  illustrates  the  appearances  seen  on  the 
screen  when  the  patient  is  suffering  from  pleurisy  with  effusion  on 
the  right  side  and  tuberculosis  at  the  left  apex :  — 


Name  "^PLOA^     -f- 

j^ddress  / 

Diagnosis 


Occupation 


/f       Date     TH/^/o 
on  Vol.  pao-e 


Fig.  141.  Mary  F.  May  18.  Third  X-ray  examination  with  screen.  Still  less  fluid  in  left  chest. 
Light  area  between  tuberculous  left  apex  and  fluid  is  larger.  A  portion  of  the  left  Ijorder  of  the  heart 
can  now  be  seen.     Excursion  of  diaphragm  on  right  side  6.3  centimetres.     (Cut  one-third  life  size.) 


Case  II.  John  J.  L.,  thirty-four  years  old,  entered  my  service  at 
the  hospital  May  10,  1899.     Diagnosis:  pleurisy  with  effusion. 

Family  History.  —  Mother  died  of  Bright's  disease,  and  her  three 
brothers  of  tuberculosis. 

Q 


2  26     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Personal  History.  —  Excessively  alcoholic ;  frequent  attacks  of 
vomiting. 

Present  Illness.  —  For  some  weeks,  pain  in  epigastrium  and  much 
vomiting  ;  slight  dry  cough  for  two  months  ;  some  loss  of  weight  but 
no  night  sweats  ;  chilly  sensations  a  week  previous  to  entrance ;  no 
dyspnoea  ;  anorexia  ;  bowels  loose. 


P/ear//)c  nffa^jon 


Jooerci/fo 


^erci//ai3 


Fig.  142.    John  y.  L.    May  29,  1899.    Cut  of  X-ray  tracing  (one-third  life  size).    Pleurisy  with  effusion 
on  the  right  side.    Heart  displaced  to  left.    Shaded  left  apex  shows  a  tuberculous  area. 


May  12.  —  Forty-three  ounces  of  clear  fluid  aspirated  from  right 
chest. 

May  18.  Physical  Examination.  —  Heart:  right  border  2  centi- 
metres to  right;  left  border  and  apex  9.5  centimetres  to  left  of  median 
line;  action  regular;  no  murmurs.  Lungs:  flatness  with  absent  breath- 
ing and  tactile  fremitus  below  mid-scapula  in  right  back  ;  resonance 
good  above  and  in  front ;  respiration  slightly  harsh,  with  expiration 
prolonged.  Left  side  :  nothing  abnormal  found  on  this  side ;  respira- 
tion good. 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


227 


May  29.  X-ray  examination  zoith  screen  showed  the  right  side 
dark  throughout ;  no  diaphragm  Hues  or  ribs  seen  ;  the  left  apex 
shaded  and  the  excursion  of  the  diaphragm  shortened  (Fig.  142). 

Tubercle  bacilli  were  found  in  the  sputum. 


Name 
Address 


^  OccupalioJ  Vol.4^2./    Page   F2  . 


Diagnosis 


Fig.  143.  Andrew  J.  K.  April  12,  1897.  First  X-ray  examination  witli  screen.  Pleurisy  with 
effusion;  much  displacement  of  heart.  The  amount  of  fluid  present  was  not  as  large  as  the  displace- 
ment of  heart  and  mediastinal  contents  (see  dark  curved  line  in  cut)  indicated.  (Cut  one-third 
life  size.) 

Case  III.     Andrew  J.   K.,  forty-seven  years  old,  entered  my  ser- 
vice at  the  hospital  April  10,  1897.      Diagnosis  :  pleurisy  with  effusion. 
Family  History.  —  Father  died  of  tuberculosis ;   mother  of  cancer. 


2  28    THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Personal  History.  —  Slight  cough  for  past  two  years. 

Present  Illness.  —  More  or  less  pain  in  left  side  since  November, 
1896.  For  five  or  six  weeks,  sense  of  oppression  in  left  chest ;  for  past  ten 
days,  constant  pain ;  some  dyspnoea ;  slight  cough ;  no  loss  of  weight. 

Physical  Examination. — Heart:  area,  action,  and  sounds  normal. 
Lungs :  good  resonance  and  respiration  over  right  chest,  front  and 
back.  Some  pain  in  left  chest  on  deep  inspiration ;  good  resonance 
over  upper  part  of  left  chest ;  respiration  somewhat  harsh  ;  dulness  at 
about  level  of  fifth  rib  and  in  left  axilla,  with  diminished  voice  sounds, 
distant  breathing,  and  diminished  tactile  fremitus.  In  left  back,  good 
resonance  down  to  2.5  centimetres  below  angle  of  scapula.  Below  this 
level  to  base  dulness,  with  diminished  vocal  and  tactile  fremitus  and 
diminished  breathing. 

April  12.  X-Ray  Examination  with  Screen.  —  Heart  displaced  to 
right  nearly  to  nipple  line;  whole  of  left  chest  dark  (Fig.    143). 

April  22.     X-?-ay  examination  the  same  as  on  April  12. 

Later,  40  ounces  of  fluid  were  withdrawn  from  the  left  chest. 

May  10.  X-Ray  Examination  zvith  Screen.  —  Left  side  darker  than 
right ;  diaphragm  seen  on  full  inspiration  ;  lower  part  of  lung  brighter 
than  upper  portion.  The  density  of  the  upper  portion  of  the  lung 
shown  by  this  examination  was  not  recognized  by  auscultation  and 
percussion  (Fig.  144). 

Judging  by  the  physical  signs  obtained  on  April  10,  I  did  not  antici- 
pate that  the  X-ray  examination  made  two  days  later  would  indicate  the 
presence  of  so  large  an  effusion  as  the  great  displacement  of  the  heart 
(see  Fig.  143)  seemed  to  show;  and  in  view  of  the  X-ray  examination 
made  on  May  10,  it  is  probable  that  this  great  displacement,  as  com- 
pared with  the  amount  of  fluid  drawn  off,  was  caused  in  part  by  the 
increased  density  of  the  left  lung. 

The  X-ray  examination  suggests  tuberculosis  at  the  left  apex, 
because  the  thorax  is  nearly  or  quite  free  from  fluid,  as  indicated  by  the 
clearness  with  which  the  diaphragm  is  seen  in  deep  inspiration.  Aus- 
cultation and  percussion  had  not  suggested  tuberculosis. 

It  is  hardly  necessary  to  point  out  how  seriously  such  appearances 
as  are  shown  in  Fig.  144,  aside  from  the  pleuritic  signs,  affect  the  prog- 
nosis. I  have  repeatedly  had  my  attention  called  to  a  beginning  tuber- 
culosis by  such  signs  in  patients  suffering  from  pleurisy  with  effusion, 
when  otherwise  the  tuberculosis  might  not  have  been  recognized  until 
a  later  stage  of  the  disease,  or  might  have  been  overlooked  altogether. 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


229 


if  only  auscultation  and  percussion  had  been  used.  It  follows,  there- 
fore, that  all  patients  with  pleuritic  effusion  should  be  submitted  to  a 
careful  X-ray  examination  before  they  are  freed  from  medical  oversight. 
If  the  X-rays  show  that  the  pulmonary  area  is  clear  and  the  excursion 


Name 

Address 

Diagnosis 


c/n-i- 


aOuu^ 


Age  Date 

Occupation 


■^  /^.  /Tf^. 


Vol. 


Page 


Fir,.  144.  Andrew  j.  K.  May  10.  Second  X-ray  examination  with  screen.  The  left  side  is  now 
nearly  or  quite  free  from  fluid,  as  the  outline  of  the  diaphragm  is  seen  in  full  inspiration.  From  the 
apex  downwards  this  side  is  increased  in  density  from  tuberculosis.     (Cut  one-third  life  size.) 

of  the  diaphragm  normal  on  both  sides,  we  have  the  best  assurance  of  a 
good  prognosis. 

Pleuritic  Adhesions.  —  As  is  well  known,  there  may  be  adhesions  of 
the  surfaces  of  the  pleurae  following  inflammation,  and  these  may  affect 


o-'O     THE    ROENTGEN    ILAYS   IN    MEDICINE    AND    SURGERY 

the  excursion  of  the  diaphragm  in  various  ways.  A  few  unusual  cases 
will  show  how  the  presence  of  these  adhesions  may  be  suggested  by 
X-ray  examinations. 

In  Fig.  127  (see  page  203,  pleurisy  with  small  effusion)  it  will  be  seen 
that  the  diaphragm  was  clearly  defined  on  the  left,  but  not  on  the  right, 
side  of  the  chest.  It  will  be  observed,  I  think,  that  even  a  very  small 
amount  of  fluid  free  in  the  pleural  sac  would  flow  into  the  angular  space 
between  the  outer  end  of  the  diaphragm  and  the  chest  wall.  Therefore, 
if  the  diaphragm  line  on  a  given  side  can  be  followed  and  this  angular 
space  is  shown  to  be  clear  by  the  X-ray  examination,  there  is  no  fluid 
present  on  this  side  unless  it  is  encysted  higher  up  in  the  chest.  Thus 
the  X-rays  give  us  assurance  of  the  absence  of  fluid  in  certain  cases  in 
which  its  absence  or  presence  is  doubtful  by  the  usual  physical  signs. 

It  is  a  simple  matter  to  prove  the  absence  of  fluid  in  the  pleural  sac 
by  means  of  the  X-rays,  but  it  is  more  difficult  to  distinguish  between 
the  presence  of  pleurisy  with  a  very  small  effusion  on  the  one  hand, 
and  a  thickened  membrane,  or  a  lung  increased  in  density  in  its  lower 
portion,  on  the  other. 

If  the  angular  space  in  the  thorax  referred  to  is  not  clear,  a  change 
in  the  position  of  the  patient  during  examination  from  a  standing  to  a 
reclining  posture,  with  the  affected  side  uppermost,  may  enable  the 
physician  to  distinguish,  on  the  one  hand,  between  fluid  free  in  the 
pleural  sac,  and,  on  the  other,  thick  adhesions  or  greater  density 
than  normal  in  the  lung.  For  example,  with  the  patient  lying  down, 
and  the  affected  side  uppermost,  an  indication  of  the  dark  area 
seen  in  the  chest  may  be  drawn  upon  the  skin,  and  the  same  process 
may  be  repeated  with  the  patient  standing.  If,  on  comparing  the 
two  sets  of  lines,  a  change  in  the  position  of  the  darkened  area  is 
seen,  this  change  might  indicate  that  there  is  liquid  present  and  not 
a  dense  lung.  If  the  dark  area  is  not  altered  by  a  change  in  the 
position  of  the  patient,  the  evidence  favors  the  view  that  it  is  caused 
by  something  other  than  liquid.  If  the  outline  of  the  diaphragm  can 
be  followed,  with  the  patient  sitting  or  standing,  to  the  outer  side 
of  the  thorax,  there  is  probably  no  free  fluid  in  the  chest. 

Case  I.  John  F.,  twenty-two  years  old,  entered  my  service  at  the 
hospital  March  14,  1899.     Diagnosis:  pleurisy  with  effusion. 

Present  Illness.  —  Chill  and  pain  in  left  side  for  two  weeks  ;  consid- 
erable cough,  with  slight  expectoration ;  headache  and  malaria ;  diar- 
rhoea for  two  days. 


PLEURISY   WITH    EFFUSION.     EMPYEMA 


2^1 


April  13.  X-Ray  Examination  ivith  Screen.  —  The  diaphragm  line  on 
the  left  side  can  be  seen  in  both  inspiration  and  expiration,  therefore  there 
is  now  little  or  no  fluid  in  the  left  chest,  but  the  excursion  of  the  dia- 
phragm is  shortened  on  this  side,  and  its  limited  movement  suggests 
that  there  are  adhesions  ;  the  darkened  area  seen  above  the  left  dia- 
phragm lines  in  the  cut  (Fig.  145)  is  due  to  thickened  pleura  or  deposit 
of  inflammatory  tissue. 


0 


Pfeurilk  Jr/he:>ion^ 


Fig.  145.  John  F.  April  13,  1899.  Cut  of  X-ray  tracing  (one-third  life  size).  Pleuritic  adhe- 
sions on  left  side,  indicated  by  the  restricted  movement  of  the  diaphragm  and  heart  on  that  side.  The 
darkened  area  at  the  lower  part  of  the  lung  may  be  due  to  thickened  membrane,  though  to  cast  a 
perceptible  shadow  it  would  have  to  be  exceedingly  thick  or  calcified. 

The  above  case  shows  how  the  X-rays  may  assist  in  indicating  the 
absence  of  fluid  in  the  pleural  sac,  and  at  the  same  time  suggest  the 
cause  of  the  remaining  difficulty. 

Case  II.  James  A.  W.,  twenty-eight  years  old,  entered  the  hospital 
October  7,  1899.  He  was  a  patient  of  one  of  my  colleagues,  and  the 
tentative  diagnosis  was  pleurisy  with  effusion  on  the  right  side. 

October  5.  Physical  Examination.  —  Lungs:  in  the  right  chest, 
from  fifth  rib  in  front,  and  from  angle  of  scapula  behind,  extending  up 
into  axilla,  flatness,  absent  respiration,  and  diminished  vocal  and  tactile 


232     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

fremitus ;    at  upper   border  of   above   area  a  few  coarse  moist   rales ; 
throughout  the  rest  of  the  chest  the  breathing  is  exaggerated. 

October  2^.  PJiysical  Examination.  —  In  right  base,  below  angle  of 
scapula  behind,  and  level  of  nipple  in  front,  there  remains  dulness  on 
percussion,  with  diminished  tactile  fremitus.  Respiratory  sounds  dimin- 
ished, but  vocal  resonance  good.     No  rales  heard. 


TlMckened  Mewhrane 


Fig.  146.    James  A.  W.     November  2,  1899.     Cut  of  X-ray  tracing  (one-third  life  size), 
area  at  right  apex,  suggestive  of  tuberculosis. 


Darkened 


November  2.  My  X-ray  examination  with  screen  showed  a  darkened 
area  at  the  right  apex,  suggestive  of  tuberculosis. 

On  the  next  day  my  colleague  found  signs  at  the  right  apex  by  per- 
cussion, and  also  signs  of  a  little  fluid  in  the  right  chest. 

If  the  tracing  made  from  this  patient  is  referred  to  (Fig.  146),  it  will 
be  also  seen  that  the  movement  of  the  diaphragm  on  the  right  side  is 
not  only  limited  but  has  an  unusual  curve.  It  moved  less  freely  in  its 
middle  portion,  and  the  outer  part  of  its  line  was  not  seen.  It  may  well 
be  that  there  was  a  small  amount  of  fluid  left  in  the  chest,  but  added  to 
this  he  probably  had  adhesions  which  limited  the  movement  of  the  dia- 


PLEURISY   WITH   EFFUSION.     EMPYEMA  233 

phragm,  particularly  in  its  outer  portion.  Whether  all  the  darkened 
area  could  be  the  result  of  a  much  thickened  pleura,  without  any  fluid, 
or  whether  we  had  to  do  with  a  small  amount  of  fluid  and  adhesions, 
would  be  a  subject  for  careful  consideration. 

A  pain  in  the  side,  or  a  "stitch  "  in  the  side  after  exertion  or  after 
cough,  or  attacks  of  pain  in  the  side  coming  on  at  irregular  intervals, 
are  sometimes  shown  by  X-ray  examination  to  be  associated  with  pleu- 
ritic adhesions.  I  have  observed  this  fact  in  a  number  of  cases,  for 
example  :  — 

Daniel  J.  R.,  one  of  my  patients  at  the  hospital,  had  attacks  of  pain 
in  the  side,  etc.  X-ray  examination  ivitJi  screeti  showed  that  the  patient 
had  emphysema,  but  also  that  the  excursion  of  the  diaphragm  on  the 
right  side  was  shorter  than  on  the  left.  His  heart  was  drawn  to  the 
right  (since  the  right  border  was  much  outside  the  sternum).  This 
change  in  position  was  not  due  simply  to  the  enlargement  of  the  right 
side  of  the  heart  which  occurs  in  emphysema,  since  I  found  the  left 
border  farther  to  the  left  than  normal.  The  position  of  the  heart  in 
this  case  may  be  most  simply  explained  by  the  presence  of  adhesions 
drawing  the  heart  to  the  right,  and  it  is  not  improbable  that  this  same 
condition  was  the  cause  of  the  attacks  of  pain  which  he  had. 

Further,  for  cases  of  this  character,  which  in  some  ways  illustrate  this 
condition  better  than  those  here  cited,  see  pages  293  and  294. 

In  patients  who  have  a  pain  in  the  side  we  should,  I  think,  consider 
not  only  the  muscles  and  nerves  of  the  chest  wall  as  the  possible  site 
of  the  trouble,  but  also  the  condition  of  the  pleuritic  membrane ;  we 
may  by  X-ray  examination  be  able  to  find  the  probable  cause.  These 
adhesions  do  not  show  themselves  on  the  fluorescent  screen  or  in  an 
X-ray  photograph,  unless  there  is  a  very  great  thickening  of  the  pleu- 
ritic membrane  ;  a  thickness  of  3  millimetres,  for  example,  would  cast  so 
little  shadow  that  it  would  not  be  seen  unless  there  was  calcification  of 
the  membrane  (Fig.  217,  Chapter  XV,  shows  a  calcified  pleura),  but  their 
presence  might  be  inferred  by  the  limitation  of  the  movements  of  the 
lungs  or  heart,  or  by  the  displacement  of  the  heart. 

An  adhesion  may  modify  the  appearances  seen  in  pleurisy  with  effu- 
sion, for  if  it  fastens  one  portion  of  the  lung  to  the  chest  wall,  the  dark 
area  caused  by  the  fluid  may  at  this  point  be  divided  into  two  parts,  as 
it  were,  and  separated  by  the  light  area  of  the  normal  portion  of  the 
lung.  In  this  case  the  outline  of  the  fluid  would  be  different  from  that 
usually  seen  in  this  disease  on  the  fluorescent  screen. 


CHAPTER    IX 

HYDROTHORAX.      PNEUMOTHORAX.      EMPYEMA  WITH   PERMANENT 
OPENING.      PNEUMOHYDRO-   OR    PNEUMOPYOTHORAX 

HVDROTHORAX 

Appearances  seen  on  the  Fluorescent  Screen  in  Hydrothorax.  —  The 
lower  portions  of  both  sides  of  the  chest  are  darker  than  normal,  and  the 
outhnes  of  the  diaphragm  cannot  be  seen.  If  the  hydrothorax  is  more 
extensive  the  dark  area  extends  higher  up  in  the  chest. 

Pneumothorax 

Appearances  seen  on  the  Fluorescent  Screen  in  Pneumothorax,  — 
(See  Fig.  147.)  The  affected  side  of  the  chest  is  unusually  clear,  and 
the  light  area  in  this  region  is  larger  than  normal ;  the  lung  is 
retracted ;  the  diaphragm  is  pushed  low  down  in  the  chest  and  has 
little  or  no  mov^ement,  and  the  organs  on  this  side  are  displaced  to 
the  opposite  side.  The  amount  of  displacement  varies  according  to 
whether  the  air  in  the  chest  is  or  is  not  under  greater  than  atmos- 
pheric pressure  ;  if  air  is  pumped  in  during  the  respiratory  movement 
through  a  valvelike  opening,  and  the  pressure  in  that  side  of  the 
thorax  is  thereby  increased,  the  displacement  of  the  organs  may  be 
very  great. 

Method  of  Examination.  —  The  patient  is  examined  lying  on  his 
back  on  a  stretcher,  and  the  appearances  above  indicated  are  traced  on 
the  skin  or  the  celluloid,  according  to  the  method  adopted. 

The  tracings  made  from  the  following  patient,  Delia  H.,  show  a 
pneumothorax  of  the  left  side.  The  heart  was  much  displaced  to  the 
right ;  the  outline  of  the  retracted  left  lung  was  not  so  clearly  seen 
in  this  patient  as  it  is  in  some  cases.  The  patient  also  had  tuberculosis 
of  the  right  lung.  The  case  is  given  because  it  illustrates  how  suc- 
cessive X-ray  examinations  show  the  gradual  improvement  that  takes 
place    in    pneumothorax    as    the    air    is    absorbed.     It  also  shows  that 

234 


HYDROTHORAX.  PNEUMOTHORAX.  EMPYEMA 


235 


subsequently  to  the  pneumothorax,  the  presence  of  pleuritic  fluid  on 
the  same  side  was  recognized  by  an  X-ray  examination,  and  these 
appearances  were  confirmed  by  tapping  the  chest. 


Fu;.  147.  Diagram  of  pneumothorax  on  left  side,  and  tuberculosis  on  right  side.  Left  side 
brighter  than  normal  and  bright  area  more  extensive.  Diaphragm  low  down  in  chest;  little  or  no 
movement.  Organs  on  left  side  displaced  to  right.  Heavy  lines  under  axillae  indicate  level  of 
nipples. 

Case  I.  Delia  H.,  twenty-five  years  old,  entered  my  service  at  the 
Boston  City  Hospital  April  3,  1898.  Alcoholic.  Had  had  much  cough 
and  expectoration.  One  week  before  had  suddenly  had  a  sharp  pain  in 
the  left  side,  which  increased.     She  was  unable  to  take  a  deep  breath. 


236     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Physical  Examination.  —  Cardiac  area  not  determined  ;  chest  hyper- 
resonant.  Apex  not  determined.  No  cardiac  sounds  heard  to  the  left 
of  sternum.  On  right  of  sternum  heart  sounds  are  heard  indistinctly, 
loudest  in  fifth  space,  sternal  border,  no  murmurs  detected.  Lungs  : 
resonance   increased    over   entire    left    lung,  front  and    back.     Tactile 


DePia  H, 


Fig.  148.  Delia  H.  First  X-ray  tracing.  Pneumothorax  of  left  side;  tuberculosis  of  right 
side.  Whole  of  left  side  abnormally  bright;  right  side  very  dark;  the  full  dark,  nearly  perpendicular 
line  gives  the  border  of  the  light  area;  the  dotted  line  indicates  the  costal  border.  The  diaphragm 
line  is  seen  to  be  very  low  down  in  the  chest  on  the  left  side;  this  side  of  the  muscle  had  little  move- 
ment during  respiration,  and  this  movement  was  chiefly  at  the  median  end,  as  if  the  motion  were  im- 
parted to  it  from  the  right  half  of  the  diaphragm.  The  outline  of  the  contracted  left  lung  was  not 
distinctly  seen,  although  in  other  cases  I  have  been  able  to  follow  it.     (One-third  life  size.) 


fremitus  and  voice  sounds  decreased  over  this  area.     Over  right  back 
there   was    marked    resonance,  and  respiration  was  broncho-vesicular. 
Many  crackling  rales  were  heard.     Over  right  front  resonance  is  fair. 
Respiration  is  here  accompanied  by  many  rales. 
April  4.     Physical  signs  the  same  as  on  April  3. 


HYDROTHORAX.  PNEUMOTHORAX.  EMPYEMA 


^Z1 


April  4.  X-ray  examination  with  screen  was  as  shown  in  the  trac- 
ing.    (See  Fig.  148.) 

The  condition  of  the  patient  on  this  day  was  serious,  and  as  I  had 
observed  that  great  rehef  is  obtained  in  cases  of  pleurisy  with  effusion 
when  the  first  part  of  the  fluid  is  drawn  off,  I  thought,  in  this  case,  the 
withdrawal  of  a  moderate  amount  of  air  would  likewise  give  relief.  I 
therefore  tapped  the  chest  of  this  patient  immediately  after  making  the 


BePia  H 


Fig.  149.  Delia  H.  Second  X-ray  tracing,  after  a  litre  of  air  had  been  withdrawn  from  the 
left  side.  The  diaphragm  was  higher,  had  soma  excursion  during  respiration,  and  the  border  of  the 
light  area  was  farther  to  the  left  of  the  median  line  than  at  the  first  examination.     (Size  one-third.) 


X-ray  examination.  A  quart  seemed  to  me  a  suitable  amount  of  air  to 
withdraw,  for  to  take  out  too  much  might  cause  the  opening  from  the 
lung  into  the  pleural  sac  to  open  again,  and  thus  require  a  repetition  of 
the  operation.  The  procedure,  devised  on  the  spur  of  the  moment,  was 
as  follows  :  — 

Mct/iod  for  witJidrazving  air.  —  I  sent  for  a  large  bottle  and  a  stop- 
per with  two  holes  in  it.  The  bottle  was  then  filled  with  water  and 
placed  on  a  table  near  the  patient.     Through  one  of  the  openings  in 


238     THE    ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 

the  stopper,  a  glass  rod  was  inserted,  which  reached  to  the  bottom  of 
the  bottle,  and  to  whose  upper  end  was  attached  a  rubber  tube,  long 
enough  to  connect  with  a  measuring  glass  on  the  floor.  This  tube  acted 
as  a  siphon  to  suck  the  water  out  of  the  bottle.  The  other  opening  in 
the  bottle  was  connected  by  means  of  a  rubber  tube  with  a  small  hollow 
needle.  The  sterilized  needle  was  inserted  into  the  left  pleural  cavity 
in  the  sixth  space  in  the  mid-a.xillary  line,  and  as  the  water  was  drawn 
out  of  the  bottle  by  the  siphon,  air  from  the  patient's  chest  was  drawn 
in.     When  a  quart  of  water  had  been  thus  withdrawn  from  the  bottle, 


DePia  H, 


Fig.  150.  Delia  H.  April  13.  Third  X-ray  tracing.  This  cut  does  not  indicate  the  dark  right 
side  of  the  thorax,  but  is  given  to  show  the  farther  improvement  in  the  position  of  the  diaphragm  and 
that  the  left  border  of  the  heart  may  be  seen.     (One-third  life  size.) 

and  a  quart  of  air  taken  out  of  the  patient's  chest,  I  lifted  the  siphon 
tube  until  water  no  longer  flowed  through  it,  and,  as  at  this  height  the 
siphon  had  some  suction  power,  I  knew  that  there  could  not  be  a  free 
opening  between  the  pleural  sac  and  the  air  in  the  lung.  The  imme- 
diate improvement  in  the  patient's  condition  was  very  marked.  Just 
before  the  operation,  the  breathing  was  shallow  and  rapid  (forty-four 
per  minute) ;  when  the  aspiration  was  stopped,  it  was  slower  and  deeper 
(thirty-five  per  minute) ;  and  soon  after  this  the  respirations  had  come 
down  to  twenty-eight  per  minute.     Not  only  was  her  breathing  made 


HYDROTHORAX.  PNEUMOTHORAX.  EMPYEMA 


239 


easy,  but  her  color  and  circulation  were  improved.  Her  change  for  the 
better  was  very  prompt  and  permanent,  so  far  as  concerned  the  pneu- 
mothorax. 

April  8.  S croud  X-Ray  Examiiiatioji  ivitJi  Screen.  —  The  dia- 
phragm moved  3  centimetres  on  the  left  side,  and  the  left  border  of  the 
heart  could  be  seen  4.5  centimetres  to  the  left  of  the  median  line.  (See 
Fig.  149-j 


Defia  ^. 


Fig.  151.      Delia  H.     May  17.     Fourth  X-ray  tracing.      Right  thorax  dark  from  tuberculosis. 
Left  chest  dark  from  pleurisy  with  effusion.     (One-third  life  size.) 


April  13.  Third  X-Ray  Examination  zvith  Screen. —  Further 
improvement ;  the  diaphragm  moved  higher  up  in  the  chest  on  the  left 
side,  and  the  left  border  of  the  heart  was  farther  to  the  left  of  the 
median  line  than  in  the  previous  examination.  On  the  right  side,  the 
right  border  of  the  heart  and  the  movements  of  the  diaphragm  could 
be  dimly  seen,  but  these  outlines  are  not  given  in  the  tracing,  as  it 
was  made  to  show  the  changed  position  of  the  diaphragm  only.  (See 
Fig.  150.) 

April  20  and  28.  X-ray  examinations  made  on  these  dates  showed 
still  further  improvement.     The  tracings  are  not  given. 


240 


THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


April  28.  The  patient  was  discharged  from  the  hospital.  The 
rio'ht  side  of  the  chest  remained  much  darker  than  normal,  owing  to  an 
extensive  tuberculous  deposit  referred  to  above. 

May  16.  The  patient  returned  to  the  hospital,  and  reported  that  she 
had  been  feeling  very  well  up  to  May  13.  Physical  examination  made 
on  May  16  showed  dulness  and  many  rales  of  every  variety  over  entire 
right  chest ;  over  lower  part  of  left  chest  there  was  dulness  and  absence 
of  voice  sounds  ;  upper  half  of  left  chest  was  hyper-resonant,  but  respi- 
ratory sounds  were  present  and  distinct.  Tubercle  bacilli  found  in 
sputum. 

May  17.  X-Ray  Exaniijiation  ivitJi  Screen.  —  The  right  chest  was 
dark,  and  there  were  signs  of  pleurisy  with  some  effusion  in  the  left 
chest.     (See  Fig.  151.) 

After  the  outlines,  from  which  this  cut  was  made,  had  been  traced, 
a  little  clear  fluid  was  withdrawn  from  the  left  side. 

Case  II.  D.  C,  twenty-eight  years  old,  entered  the  hospital 
August  30,    1896.     In  the  service  of  Dr.  G.  G.  Sears.     Alcoholic. 

History.  —  On  August  26,  6  p.m.,  felt  a  sudden  pain  in  the  left  side; 
no  dyspnoea. 

******** 

September  3.  Physical  Exa))ii)iation.  —  Tympanitic  note  over  whole 
of  right  front,  amphoric  respiration  marked  at  right  base,  with  metallic 
tinkling.  Over  upper  and  lower  thirds  of  right  front,  axilla,  and  right 
base,  marked  amphoric  voice  and  whisper.  Edge  of  liver  could  not  be 
felt.      Heart  dulness  a  finger's  breadth  to  left  of  sternum. 

September  4.  X-ray  examination  zvith  screen  that  Dr.  Sears  kindly 
allowed  me  to  make  at  my  request.  Whole  of  right  side  was  clear ; 
bright  area  extended  far  down  and  over  to  the  left  side.  Diaphragm  on 
left  side  extended  nearly  to  the  lower  costal  border ;  its  motion  on  inspi- 
ration and  expiration  was  much  limited  ;  its  median  end  had  more  motion 
than  the  outer  end.  The  appearances  on  the  left  side  were  unusual ; 
there  were  two  bright  areas  divided  from  each  other  by  a  vertical  dark 
area  which  included  the  heart.  The  heart  was  pushed  far  to  the  left 
with  the  lung  and  vessels.  The  examination  was  not  complete,  as  the 
patient  was  not  strong. 

The  displacement  of  the  heart  and  lung  was  so  much  greater  in  this 
patient  than  is  found  in  patients  with  a  permanent  opening  in  the  chest, 
as  after  an  operation  for  empyema,  that  the  air  in  the  right  side  of  the 
thorax   was  probably  under  more  than  the   atmospheric  pressure,  and 


HYDROTHORAX.  PNEUMOTHORAX.  EMPYEMA 


241 


had  probably  been  pumped  into  the  pleural  sac  through  a  valvelike 
opening. 

ScptcDibcr  5.  Physical  examination  showed  that  the  apex  beat  was 
in  the  fifth  space,  3.7  centimetres  outside  the  left  nipple  line.  Patient 
rather  cyanotic,  respiration  somewhat  hurried.  Right  chest  somewhat 
more  prominent  than  left,  but  moved  well  with  inspiration.  Metallic 
tinkling  was  absent.  Edge  of  Uver  could  not  be  felt,  as  patient's 
muscles  did  not  easily  relax. 

These  patients  show,  I  think,  that  the  X-ray  examinations  may 
assist  us  to  determine  the  exact  conditions  present  in  this  class  of 
cases.  I  have  never  appreciated  these  conditions  so  clearly  as  by 
means  of  an  X-ray  examination. 

Empyema  with  Permanent  Opening 

The  appearances  seen  on  the  screen  vary  with  the  amount  of  lung 
involved ;  the  amount  of  diseased  tissue  present  in  the  chest  which  is 
denser  than  the  lung ;  the  extent  of  the  cavity  ;  the  pleuritic  adhesions, 
etc.  That  is  to  say,  the  darkened  area  is  more  or  less  extensive,  and 
varies  in  its  degree  of  darkness  in  accordance  with  the  absence  or 
presence  of  the  conditions  just  enumerated.  The  diaphragm  is  seen 
to  be  more  or  less  depressed,  but  not  to  the  extent  represented  in  the 
diagram  of  pneumothorax. 

After  a  permanent  opening  has  been  made  in  empyema,  X-ray 
examinations  may  be  serviceable  by  enabling  the  physician  to  recognize 
how  large  the  sinus  is.  This  point  may  be  ascertained  by  injecting 
iodoform  in  suspension,  or  subnitrate  of  bismuth,  or  a  solution  of  iodide 
of  potassium,  or  even  sterilized  water,  as  all  these  substances  cast  a 
shadow  on  the  screen  ;  the  X-rays  will  also  be  of  use  in  showing  the 
condition  of  the  lung,  —  how  much  it  is  able  to  expand  as  improvement 
takes  place,  and  whether  or  not  there  is  an  accompanying  tuberculosis. 

Pneumohvdrothorax  —  Pneumopyothorax 
Pneumohydrothorax,  or  Pneumopyothorax,  like  empyema  and  pleu- 
risy, is  usually,  of  course,  a  symptom  rather  than  a  disease,  and,  except 
when  caused  by  trauma,  should  suggest  tuberculosis. 

Appearances  seen  on  the  Fluorescent  Screen.  Sitting  Position.  —  When 
the  patient  is  examined  while  sitting  up,  with  the  tube  behind  him,  about 
on  the  level  with  the  fourth  rib,  and  the  screen  on  the  front  of  the  chest, 
the  affected  side  is  seen  to  be  divided  into  two  parts,  the  upper  of  which 


242 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


is  unusually  light  and  the  lower  very  dark.  The  general  appearances 
on  this  side  may  be  likened  to  a  tumbler  partially  filled  with  ink ;  when 
the  patient  moves  backward  or  forward,  the  level  of  the  fluid  changes ; 
if  he  is  taken  by  the  shoulders  and  gently  shaken,  the  surface  is  dis- 
turbed, and  the  splashing  of  the  fluid  is  clearly  seen.     When  the  fluid 


Fig.  152.  Diagram  of  pneumohydrothorax.  Left  side.  Sitting  position.  Level  line  of  fluid 
seen  in  left  chest.  Heart  displaced  to  right.  Retracted  left  lung  not  indicated;  it  would  make  a 
slight  shadow  in  upper  portion  of  left  chest. 

is  at  a  certain  level,  especially  if  the  pneumohydrothorax  is  in  the  left 
side,  the  pulsations  of  the  heart  disturb  its  surface,  and  the  waves  caused 
by  the  partially  submerged  and  beating  heart  can  be  observed. 

In  the  upper  portion  of  the  chest,  and  toward  the  median  line,  the 
slight  shadow  of  the  retracted  lung  may  often  be  seen  ;  if  the  lung  is 


HYDROTHORAX.  PNEUMOTHORAX.  EMPYEMA 


243 


tuberculous,  it  would  be  darker  than  if  it  were  not  diseased,  and  would 
not  be  so  much  retracted  as  if  it  were  healthy.  The  heart  is  much  dis- 
placed to  the  opposite  side.  The  fluid  may  be  seen  to  rise  with  inspira- 
tion, because  of  the  pushing  up  of  the  diaphragm  on  the  diseased  side 
when  this  muscle  descends  on  the  well  side  and  to  fall  with  expiration. 


CPW: 


'"W^ 


Fig.  153.  C.  P.  VV.  Pneumohydrothorax  on  left  side.  Appearances  seen  with  patient  sitting 
up.  (Wiien  lying  down,  the  whole  of  the  left  side  was  dark.)  Tuberculosis  at  right  ape.x.  Heart 
drawn  to  the  right.  The  level  of  the  fluid  sharply  defined,  as  indicated  by  the  dark  line  over  the 
fourth  rib  on  the  left  side.  When  the  patient  was  inclined  to  the  right  or  to  the  left,  the  surface  of  the 
fluid  remained  level.  When  the  patient  was  gently  shaken,  the  splashing  of  the  fluid  could  be 
followed.     (One-third  life  size.) 


It  is  said  that  the  fluid  may  rise  slightly  with  each  systole  while  the 
breath  is  held,  but  I  have  not  seen  it.  The  expansion  of  the  lung, 
consequent  upon  the  subsidence  of  the  fluid  and  the  absorption  of  the 
air,  may  be  watched  upon  the  screen  if  the  perforation  closes. 

The  tracing  given  above  (Fig.  153)  also  illustrates  the  appearances 
seen  on  the  screen  in  pneumohydrothorax.     The  patient  from  whom  it 


244     'I^HK    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

was  made  was  in  the  service  of  Dr.  Buckingham,  but  was  examined  by 
me  with  the  X-rays  on  June  5,  1897.  This  examination  also  suggested 
that  the  patient  had  a  tuberculous  infiltration  of  the  right  apex,  and 
this  indication  was  confirmed  later  by  the  finding  of  tubercle  bacilli  in 
the  sputum. 

On  June  17,  Dr.  Buckingham  withdrew  39  ounces;  on  June  29,  45 
ounces ;  and  on  August  6,  64  ounces  of  fluid  from  the  chest.  The 
patient  was  discharged  from  the  hospital,  September  25,  1897,  improved  ; 
he  had  gained  15  pounds. 

Rcciiuibcnt  Position.  —  If  the  patient  is  examined  lying  flat  on  his 
back  with  the  tube  below  him  and  the  screen  on  the  front  of  his  chest, 
the  whole  of  the  affected  side  is  seen  to  be  dark,  because  the  fluid  dis- 
tributes itself  over  the  whole  of  this  side  of  the  thorax  ;  the  appearances 
seen  resemble  those  observed  in  pleurisy  with  large  effusion  ;  in  pleurisy 
with  small  effusion,  as  already  shown,  the  dark  area  in  the  lower  part 
of  the  chest  shades  off  into  the  lighter  area  above,  the  fluid  remains 
near  the  diaphragm,  and  changes  its  position  comparatively  little. 

The  affected  side  of  the  chest  will  present  a  different  appearance 
with  the  patient  in  this  same  position,  if  the  position  of  the  tube  and 
screen  is  changed.  If  the  tube  is  placed  opposite  and  a  little  below  the 
centre  of  the  side  of  the  thorax,  and  one  end  of  the  screen  is  rested  on 
the  chest  and  the  other  is  a  little  raised,  the  X-rays  will  enter  the  chest 
above  the  fluid,  and  a  light  area  will  be  seen  on  the  screen,  because,  as 
we  have  just  seen,  the  fluid  gravitates  to  the  back  of  the  chest  when 
the  patient  is  lying  down. 

This  condition  of  things  can  be  still  better  shown  in  some  instances 
if  the  patient,  after  lying  down,  turns  a  little  on  one  side  as  the  fluid, 
instead  of  being  distributed  evenly  over  the  back  of  the  chest,  flows  in 
toward  the  sternum  and  gives  the  X-rays  a  still  better  opportunity  to 
demonstrate  the  air  in  the  portion  of  the  thorax  near  the  front  of  the 
chest  wall. 

The  following  tracing  is  taken  from  the  chest  of  a  boy  five  years 
old,  a  patient  of  Dr.  H.  W.  Gushing  on  the  surgical  side  of  the  hospital, 
whom  I  examined  with  the  X-rays,  and  represents  the  appearances  seen 
both  when  the  patient  is  sitting  up  and  lying  down. 

In  the  former  position  the  fluid  rose  to  the  level  indicated  in  the  X-ray 
tracing  by  the  full  horizontal  line  just  above  the  nipple.  The  chest 
below  this  point  was  dark,  while  above  this  line  it  was  light,  as  in  the 
case  of  C.  P.  W.     When  the  boy  was  lying  down  the  fluid  distributed 


HYDROTHORAX.  PNEUMOTHORAX.  EMPYEMA 


245 


itself  over  the  chest,  as  shown  by  the  crossed  lines  above  the  horizontal 
line.  This  tracing  also  indicates  that  the  position  of  the  diaphragm 
in  pneumohydrothorax  may  be  similar  to  that  in  pneumothorax. 

Immediate  Relief  by  Operation.  —  In  pneumohydrothorax  the  press- 
ure may  become  so  great  that  the  patient  may  be  in  imminent  danger. 
It  seems  to  me  probable  that  this  serious  condition  may  be  due  to  a 
valvelike  perforation  that  allows  the  air  to  be  drawn  in  but  does  not 
permit  it  to  go  out,  so  that  the  amount  of  air  in  the  affected  side  of  the 


Fig.  154.  Tony  M.  Five  years  old.  Tracing  one-third  life  size.  Pneumohydrothorax  (traumatic). 
Recumbent  position. — This  tracing,  with  the  omission  of  the  horizontal  line  on  the  left  chest, 
indicates  the  appearances  seen  on  the  screen  when  the  patient  was  recumbent  and  the  tube  below 
him.  That  is,  the  chest  was  darkened  throughout ;  the  diaphragm  was  low  down  in  the  thorax, 
and  the  heart  was  drawn  to  the  left.  Sitting  position.  —  When  the  patient  sat  up  and  the  tube  was 
behind  him,  on  a  level  with  the  fourth  rib,  the  left  chest  below  the  horizontal  line  was  dark,  and  above 
it  very  bright.  This  horizontal  line  indicates  the  level  of  the  fluid.  The  fluid  remained  level  when 
the  patient  bent  from  side  to  side. 


chest  increases  to  such  an  extent  as  to  displace  the  heart  to  a  marked 
degree ;  that  is,  the  pressure  from  within  becomes  greater  than  the 
pressure  from  without.  Tapping  the  chest  in  such  cases  gives  immedi- 
ate relief,  and  the  X-rays  enable  us  to  estimate  the  amount  of  displace- 
ment of  the  organs,  the  quantity  of  air  present,  and  whether  or  not  an 
operation  should  be  done  directly.  The  following  case  illustrates  the 
danger  to  which  a  patient  suffering  from  pneumohydrothorax  may  be 
subjected  :  — 


246     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

The  patient,  Daniel  S.,  thirty-five  years  of  age,  was  in  my  service  at 
the  Boston  City  Hospital.  He  was  unconscious  and  evidently  in  a  dying 
condition.  I  inserted  a  hollow  needle  into  the  left  chest  between  the 
axillary  lines,  while  the  patient  was  lying  on  his  back ;  when  it  was 
directed  so  that  its  point  was  toward  the  back  of  the  chest  the  fluid 
ran  out ;  when  the  needle  was  reversed,  the  air  came  out.  The  opera- 
tion gave  immediate  relief. 

In  conclusion,  in  these  conditions  or  diseases  the  X-rays  give  less 
equivocal  and  more  complete  evidence  than  can  be  obtained  by  the 
physical  signs. 


CHAPTER  X. 
SECTION  I 

NORMAL  AND  ABNORMAL  HEART 

X-Ray  Examinations  of  the  Heart.  —  In  order  to  determine  the 
borders  of  the  heart  with  the  X-rays,  it  is  essential  that  the  lungs  and 
pleurae  be  clear.  If,  for  example,  the  lung  is  dense  on  the  left  side  in 
its  lower  portion,  it  will  be  impossible  to  distinguish  the  left  border  of  the 
heart ;  or  if  there  is  pleuritic  effusion  on  the  left  side,  of  a  considerable 
amount,  it  would  likewise  be  impossible  to  determine  this  border.  In  a 
word,  it  is  evident  that  X-ray  examinations  cannot  be  used  to  determine 
the  borders  of  the  heart  unless  the  contrast  between  this  denser  organ 
and  the  lighter  pulmonary  area  is  sufficiently  marked. 

The  heart  may  be  examined  when  the  patient  is  standing,  sitting,  or 
lying  down.  Let  us  suppose  first  that  he  is  placed  flat  on  his  back,  exactly 
in  the  middle  of  the  canvas  stretcher  already  described  ;  that  the  posi- 
tion of  the  vacuum  tube  has  been  determined  by  the  plumb-lines ;  and 
that  the  target  has  been  placed  under  the  stretcher  about  75  centimetres 
(30  inches)  away  from  the  screen,  and  at  the  point  where  the  median 
line  crosses  the  fourth  rib.  Since  to  get  accurate  results  it  is  necessary 
that  the  two  sides  of  the  body  be  at  equal  distances  from  the  tube,  a 
small  level  may  be  placed  across  the  sternum  to  make  sure  that  one  side 
is  not  higher  than  the  other.  Now  let  us  place  the  fluorescent  screen  on 
the  chest  and  examine  the  normal  heart. 

Appearan'ces  seen  on  the  Fluorescent  Screen 

Normal  Heart. —  The  heart  hangs  in  the  thorax,  resting,  during 
expiration,  on  the  diaphragm,  in  such  a  position  that  its  long  axis  is  at 
an  angle  with  the  median  Hue  of  the  body.  But  when  a  deep  breath  is 
taken,  as  I  pointed  out  in  1896,^  the  outhnes  of  the  heart  can  be  seen 

1  "A  Method  for  more  fully  determining  the  Outline  of  the  Heart  by  Means  of  the  Fluoro- 

scope,  together  with  Other  Uses  of  this  Instrument  in  Medicine,"  Boston  Medical  and  Surgical 

Journal,  October  i,  1896. 

247 


248     THE    ROENTGEN    RAYS    IX    MEDICINE    AND    SURGERY 

most  fully.  At  this  time  the  heart  moves  downward  and  inward,  the 
whole  of  the  left  border  is  clearly  seen,  and  the  right  border  also  becomes 
visible  on  the  right  side  of  the  sternum  ;  therefore  the  best  view  of  the 
heart  is  then  obtained.  In  other  words,  the  inclination  of  the  long  axis 
of  the  heart  becomes  more  horizontal  as  the  diaphragm  rises  in  expira- 
tion, and  more  vertical  as  the  diaphragm  descends  during  deep  inspira- 
tion, and  this  change  in  direction  of  its  axis  takes  place  chiefly  during 
the  latter  portion  of  the  descent  of  the  diaphragm,  when  its  pull  on  the 
pericardium  becomes  stronger  and  the  lungs  distend.  At  this  latter 
period  of  the  respiratory  movements  the  transverse  diameter  of  the  heart 
is  somewhat  diminished,  and  its  pulsations  are  lessened  in  amplitude. 
This  temporary  decrease  in  diameter  and  shortening  of  the  pulsations 
of  the  heart  seem  to  be  partially  due  to  the  downward  pull  of  the 
diaphragm  to  which  reference  has  just  been  made.  The  axis  of  the 
normal  heart  is  more  inclined  in  some  persons  than  in  others,  a  point 
which  will  be  considered  when  discussing  the  accuracy  of  percussion. 

In  quiet  breathing  both  borders  of  the  heart  may  be  well  seen  in  some 
individuals,  and  in  such  cases  this  organ  can  be  measured  at  that  time. 
In  those  cases  where  they  cannot  both  be  well  seen  at  this  time,  the 
left  border  can  be  first  traced  on  the  skin  or  celluloid,  as  the  case  may 
be.  and  when  a  little  further  inspiration,  before  full  inspiration  is  reached, 
brings  the  right  border  into  better  view  that  may  be  added. 

The  heart  can  be  better  seen  during  full  inspiration  than  during  expi- 
ration, for  the  following  reasons  :  First,  the  diaphragm  descends  dur- 
ing the  former  part  of  the  respiratory  period,  and  therefore  a  much 
larger  portion  of  the  cardiac  outline  is  brought  into  view.  Second,  the 
lungs  are  more  transparent  to  the  rays  during  deep  inspiration,  and 
therefore  the  pulmonary  area  on  the  screen  is  brighter,  and  consequently 
the  contrast  between  it  and  the  heart  is  more  marked.  The  right  side 
of  the  heart  is  better  seen  because  this  organ  is  a  little  more  to  the  right 
in  full  inspiration  than  in  expiration.  The  inferior  vena  cava  (as  also 
the  superior)  is  pushed  toward  the  median  line,  and  the  blood  vessels 
in  the  right  lung,  which  have  a  direction  downward  and  outward  from 
the  root  of  the  lung,  are  carried  farther  from  the  median  line  of  the 
body,  so  that  the  right  border  is  more  clearly  seen  during  deep  inspira- 
tion because  the  blood  vessels  whose  shadow  would  tend  to  confuse  and 
obscure  it  are  moved  from  the  position  which  they  hold  during  expira- 
tion. Full  inspiration  is  therefore,  as  a  rule,  the  best  time  for  measur- 
ing the  transverse  diameter  of  the  heart ;  but  it  must  be  remembered  that 


NORMAL    AND    ABNORMAL    HEART 


249 


the  more  vertical  position  of  the  heart's  axis  obtaining  at  this  time 
makes  the  horizontal  distance  between  its  right  and  left  borders  less 
than  during  expiration,  at  which  time  the  axis  of  the  heart  is  more 
inclined,  so  that  the  width  of  this  organ,  measured  at  deep  inspiration, 
varies  from  that  obtaining  at  expiration. 

The  following  cut  (Fig.  155)  is  a  reproduction  of  an  X-ray  photo- 
graph of  the  heart  ^  which  I  took  during  a  full  inspiration.  The  cut  is 
about  one-half  the  original  size  of  the  photograph,  and  shows,  above  the 
fourth  ribs,  the  outer  border  of  the  superior  vena  cava  and  of  the  aorta ; 
below  the  fourth  ribs,  the  heart.  The  diaphragm  is  seen  at  the  bottom 
of  the  picture. 

The  pulsations  of  the  heart  diminish  the  sharpness  of  the  outlines 
of  this  organ  in  the  X-ray  photograph,  and  in  the  process  of  repro- 
ducing this  photograph  the  clearness  even  of  the  original  is  lost. 
The  dark  areas  on  each  side  of  the  heart,  which  have  in  general  a 
direction  downward  and  outward,  are  the  shadows  of  the  pulmonary 
vessels.  In  the  original  negative,  there  is  seen  on  the  right  side,  above 
the  heart,  the  outline  of  the  outer  side  of  the  superior  vena  cava,  and 
within  it,  that  of  the  ascending  aorta.  The  curve  of  the  descending  aorta 
may  be  easily  followed  in  the  negative,  but  is  almost  lost  in  the  half- 
tone ;  in  the  original,  nearly  the  whole  of  the  outer  curve  of  the  ascend- 
ing, transverse,  and  descending  arches  of  the  aorta  may  be  followed. 

As,  then,  the  heart  may  be  measured  during  different  stages  of  the 
respiratory  movements,  the  period  at  which  the  measurement  has  been 
taken  should  be  noted,  so  that  if  a  second  examination  of  a  given  heart 
be  made,  for  the  purpose  of  comparison,  the  same  period  may  be  used. 
Likewise  the  period  at  which  the  measurement  has  been  taken  is  of 
importance,  and  should  be  noted  if  tables  giving  the  widths  of  a  large 
number  of  hearts  are  being  compiled  for  the  purpose  of  comparison 
with  some  other  method  of  examination,  or  for  other  purpose. 

Levy-Dorn,  at  the  meeting  noted  below,^  showed  two  pictures  of  the 
heart,  the  one  in  deep  inspiration,  the  other  during  forced  expiration  ; 
and  they  indicated  that  the  diameter  of  the  heart  was  greater  during 
expiration. 

Pulsations.  —  The  pulsations  of  the  heart  seem  to  be  less  marked 
during  full    inspiration    than  during    expiration,  or  the    inspiration    of 

1  Communications  of  Mass.  Med.  Society,  June  13,  1899. 

2"Zur  Untersuchung  des  Herzens  mittels  Roentgenstrahlen,"  Verhandlungen  des  Con- 
gresses fiir  Innere  Medicin,  1899,  also  Fortschritte  a.  d.  Geb.  d.  Rontgenstr.,  p.  216,  B.  II,  1898. 


Fig.  155.     Half-tone  of  radiograph  of  heart  of  a  man  forty-seven  years  old,  taken  during  a  full  inspira- 
tion.    He  was  lying  on  his  back  on  the  stretcher,  with  the  plate  on  the  front  of  his  chest. 


Fig.  156.    Half-tone  of  radiograph  of  heart  of  the  same  man  as  in  Fig.  155,  taken  during  quiet  breath- 
ing (about  the  position  of  expiration). 


252     THE    ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 

quiet  breathing.  This  diminution  in  the  extent  of  the  pulsations  may 
be  due  to  several  causes  :  to  the  descent  of  the  heart  when  the  dia- 
phragm is  lowered  ;  to  the  stretching  of  the  pericardium  by  the  descent 
of  the  diaphragm ;  and  to  the  turning  of  the  heart  so  that  a  portion 
with  less  amplitude  of  pulsation  is  silhouetted  on  the  screen. 

The  pulsations  of  the  left  border  of  the  heart  may  be  best  followed 
on  the  fluorescent  screen  during  full  inspiration,  and  the  observer  may 
easily  see  that  it  changes  its  outline  chiefly  over  the  cavity  of  the  left 
ventricle,  toward  the  base  of  the  heart,  and  that  its  apex  does  not 
shorten  very  much.  The  pulsations  of  the  right  ventricle  may  be 
followed,  when  its  border  is  clearly  defined  beyond  the  edge  of  the 
sternum,  during  full  inspiration,  and  in  some  cases  in  the  inspiration 
of  quiet  breathing ;  and  may  be  more  fully  observed  at  these  periods 
than  during  expiration.  After  a  full  breath  has  been  held,  the  pulsa- 
tions of  the  ventricle  are  not  only  more  rapid,  but  more  ample  during 
the  succeeding  expiration. 

The  right  auricle  casts  a  faint  shadow  on  the  screen,  and  its  pul- 
sations may  be  followed  in  health  under  favorable  conditions,  that 
is  to  say,  if  the  apparatus  is  good  and  the  individual  is  thin  ;  but 
more  easily  if  emphysema  is  present  or  if  the  auricle  is  distended  by 
disease. 

The  pulsations  of  the  ventricle  are  more  easily  seen  than  those  of 
the  auricle,  because  the  former  is  denser  and  therefore  casts  a  more 
marked  shadow.  The  physician  should  become  familiar  with  the  char- 
acter of  the  pulsations  and  their  ampHtude  in  health,  for,  as  we  shall 
see  later,  they  may  be  modified  in  cardiac  disease. 

The  heart  does  not  work  to  its  full  capacity  when  the  individual  is- 
quiet,  but,  like  the  lungs,  can  be  called  upon  to  do  much  more  when 
required.  The  excursions  from  systole  to  diastole  are  seen  on  the 
screen  to  be  ampler  after  active  exercise. 

Apex  Beat.  —  The  impulse  felt  on  the  chest  wall  is  not  always  the 
beat  of  the  apex  of  the  heart ;  but  in  health  is  sometimes  the  blow  given 
by  the  ventricle  against  the  chest  wall.  This  point  is  easily  demon- 
strated by  the  X-rays,  for,  on  looking  into  the  chest,  the  anatomical  apex 
may  sometimes  be  seen  lower  down  than  the  point  where  the  impulse 
is  felt.  In  disease,  when  the  heart  is  displaced  to  the  right,  the  impulse 
felt  to  the  right  of  the  sternum  and  attributed  to  the  apex,  is  in  some 
instances  the  blow  from  the  right  ventricle.  The  following  case  is 
illustrative :  — 


NORMAL  AND   ABNORMAL   HEART  253 

Bernard  McL.,^  nineteen  years  old,  entered  my  service  at  the  hos- 
pital February  11,  1897.      Diagnosis:  pneumonia. 

February  13.  X-ray  exaviiiiation  ivitJi  screen  showed  in  the  right 
lung  a  dark  area,  well  defined  above  and  below,  as  indicated  in  the 
tracing  (see  Fig.  106,  chapter  on  Pneumonia),  and  that  the  outUnes  in 
the  whole  chest  were  rather  less  clear  than  normal. 

The  apex  beat  of  the  heart,  indicated  in  the  tracing  by  the  letter  A, 
appeared  to  be  in  the  fourth  interspace  8.25  centimetres  from  the  mid- 
sternal  line,  whereas  the  X-ray  examination  showed  that  the  real  apex 
of  the  heart  was  more  than  2.5  centimetres  below  this  point. 

If  the  apex  beat  is  especially  well  marked,  it  suggests  that  the  pul- 
sations are  stronger  than  normal,  or  that  the  heart  is  held  against  the 
thoracic  wall  more  firmly  than  usual,  either  by  a  lung  denser  than 
normal  or  by  a  somewhat  emphysematous  lung.  If  the  lung  is  so 
emphysematous  that  it  intervenes  between  the  heart  and  the  chest 
wall,  of  course  the  apex  beat  could  not  be  seen  on  the  chest  by  the 
unaided  eye. 

It  is  evident  that  in  studying  the  heart  it  is  well  to  examine  its  out- 
lines on  the  fluorescent  screen,  during  both  inspiration  and  expiration, 
but  they  are  most  fully  brought  out  when  the  patient  takes  a  deep 
breath.  If  studied  during  the  various  phases  of  the  respiratory  move- 
ment, nearly  the  whole  of  the  left,  and,  as  a  rule,  more  or  less  of  the  right, 
border  of  the  ventricles  may  be  seen.  The  following  diagram  is  illus- 
trative of  this  (Fig.  157):  — 

Experiments   made    by    Ludwig  and    Hesse    on   the  Form  of  the 
Heart  in  Systole  and  Diastole 

In  connection  with  the  changes  in  the  size  of  the  normal  heart  as 
seen  on  the  fluorescent  screen,  the  experiments  made  by  Ludwig  and 
Hesse  on  the  physiology  of  this  organ,  and  published  in  1880  ("  Beitrage 
zur  Mechanik  der  Herzbewegung,"  Arch,  fiir  Anat.  nnd  Phys.,  p.  329) 
are  of  interest.  I  will  therefore  take  up  this  subject  briefly,  using  for 
the  most  part  the  lecture  by  Donald  Macalister  ("  Remarks  on  the  Form 
and  Mechanism  of  the  Heart,"  Brit.  Med.  Jour.,  October  28,  1882), 
though  practitioners  who  are  interested  in  this  question  will  find  it  well 
worth  while  to  consult  the  original. 

^  This  case  and  the  tracing  are  given  in  the  chapter  on  Pneumonia,  so  that  further  details 
are  unnecessary  here. 


254 


THE   ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 


"  Galen  and  Vesalius  taught  that  the  heart  lengthened  in  systole ; 
Harvey  that  it  shortened.     In  the  seventeenth  century  the  famous  medi- 


FiG.  157.     Diagram  of  heart  movements. 

Diagram  representing  the  borders  of  the  blood  vessels,  heart,  and  diaphragm  —  the  full  lines  in 
deep  inspiration,  the  broken  lines  in  expiration,  the  dotted  lines  just  below  the  broken  ones  the 
position  of  the  diaphragn   in  ordinary  mspiration. 

The  line  of  large  and  small  dots  inside  the  left  border  of  the  heart  shows  the  position  of  the  left 
border  in  systole,  the  full  line  in  diastole,  during  full  inspiration.  The  other  movements  of  the  heart  — 
namely,  those  of  the  apex,  the  right  ventricle,  and  the  right  auricle  —  are  not  indicated  in  the  diagram. 

cal  schools  of  Montpellier  and  Paris  fought  fiercely,  but  chiefly  with  dialec- 
tic weapons,  on  Galen's  side  and  on  Harvey's,  respectively.  At  length 
Bassuel  asked  triumphantly,  '  How,  if  the  ventricle  lengthens,  can  the 


NORMAL   AND    ABNORMAL   HEART 


255 


auricular  valv^es,  anchored  to  its  walls  by  the  tendinous  cords,  ever  suc- 
ceed in  closing  ? '  No  answer  was  forthcoming  from  the  south,  and  so 
victory  remained  in  Paris.  Since  then  the  text-books  tell  you  that  the 
heart  shortens  when  it  contracts.  It  is  not  hard  to  see  how  Harvey, 
and  other  observers  since,  have  got  this  impression  from  watching  the 

still  acting  heart  /;/  j* ////." 

******** 

The  procedure  adopted  by  Ludwig  and  Hesse  to  obtain  the  form  of 
the  heart  in  diastole  and  systole  was  as  follows  :  — 

"  A  dog  is  rapidly  bled  from  the  carotids  ;  the  chest  is  opened  ; 
the  auricular  vessels  are  ligatured  ;  straight,  graduated  glass  tubes  are 
tied  into  the  pulmonary  artery  and  the  aorta,  and  the  heart  is  then 
removed  from  the  body  and  suspended  by  the  tubes,  which  are  kept 
vertical.  The  blood  of  the  animal  has  been  meanwhile  freed  from 
fibrin,  and  it  is  now  poured  into  the  vertical  tubes  so  as  to  dilate  the 
ventricles,  until  the  pressure  is  equal  to  the  mean  blood  pressure  during 
life  (150  millimetres).  The  auricles  at  once  begin  to  pulsate  rhyth- 
mically, and  continue  to  do  so  for  nearly  an  hour.  The  ventricles  remain 
soft,  pliable,  and  irritable  all  this  time.  The  heart  muscle,  in  contact 
with  nutrient  blood,  and  prevented  from  cooling  or  drying,  is  in  fact 
alive.  Certainly  for  the  first  few  moments  of  this  hour  no  change  in 
its  vital  properties  can  have  occurred.  Little  pins  are  quickly  inserted 
into  the  muscle  at  certain  spots  to  serve  as  reference  marks,  and  then 
a  thin  layer  of  very  quickly  setting  plaster  is  hghtly  applied.  A 
minute  or  two  is  enough  to  let  this  harden  sufificiently,  and  then  it  is 
broken  off  by  a  skilled  hand,  who  is  able  to  set  together  the  pieces 
again,  and  so  to  form  a  mould  from  which  casts  may  be  taken.  .  .  . 
It  was  in  this  way,  then,  that  this  cast  of  the  diastolic  heart  was 
made.   ..." 

"  To  obtain  this  [a  cast  of  the  same  heart  in  typical  systole]  the  heart, 
still  living  and  uninjured  (for  the  auricles  still  pulsate),  is  emptied  of 
blood,  and  then  plunged  quickly  into  a  hot  saturated  solution  of  bichro- 
mate of  potassium  at  50°  Cent.  (Fahr.  122°).  One  rapid  and  final  con- 
traction of  the  ventricular  muscles  takes  place  ;  this  is  permanent,  for 

j  the  muscle  passes  into  rigor  caloris,  .  .   .  and  in  this  state  it  is  fixed,  and 

■  its  textures  hardened,  without  shrinkage  or  alteration  by  the  bichromate. 

i  We  can  let  it  stay  in  the  solution  till  the  hardening  is  complete,  and  take 

i  a  cast  of  its  outward  form  at  leisure." 

i        Casts  of  the  outward  form  of  the  heart  being  thus  obtained,  Ludwig 


256     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

and  Hesse  proceeded  to  get  casts  of  the  form  of  the  cavities  of  each 
ventricle.  The  method  was  necessarily  different,  for,  although  plaster 
could  be  poured  into  the  dilated  cavities,  the  mould  could  not  be  set  free 
without  destroying  the  heart.  Therefore,  after  making  preliminary  exper- 
iments with  several  pairs  of  young  dogs,  two  were  taken  of  the  same 
make  and  size  from  the  same  litter.  They  were  similarly  fed  and  grew 
together,  and  it  was  found  after  death  that  the  hearts  were  similar  as 
were  the  dogs.  The  heart  of  one  of  these  dogs  was  dilated,  as  in  the 
first  experiment,  with  its  own  blood,  and  then  lowered  into  cool  bichro- 
mate solution  ;  it  was  thus  slowly  hardened  in  its  diastolic  form.  The 
heart  of  the  other  was  brought  to  contract  by  hot  bichromate  solution 
and  hardened  in  systole.  When  the  hardening  was  complete,  casts  of 
the  cavities  were  made  in  plaster  or  fusible  metal,  and  corresponding 
transverse  sections  of  the  two  hearts  were  cut  to  show  the  relation  of 
the  walls  to  the  lumen.  On  comparing  these  corresponding  transverse 
sections  it  was  found  that  the  muscle  area  was  the  same  in  systole  and 
diastole.  Any  change  in  the  contents  of  the  outer  circumference  was 
entirely  at  the  expense  of  the  lumina.  This  experiment  shows  that  the 
systole  is  effected  by  the  diminution  of  the  cross  section  everywhere 
without  change  of  the  length. 

The  article  goes  on  to  indicate  the  reason  why  the  heart  changes  its 
form  in  this  way. 

"  The  arrangement  of  the  muscular  fibres  of  the  heart  is  extremely 
complex.  If  it  were  composed  of  circular  fibres  alone,  it  is  plain  that, 
as  they  contracted  so  that  the  circumference  of  each  ring  shortened,  its 
thickness  must  at  the  same  time  increase.  The  result  would  be  that 
the  heart  would  lengthen  on  the  whole.  If  the  heart  were  mainly  made 
of  longitudinal  fibres,  they  would  thicken  and  shorten  simultaneously 
when  they  contracted,  and  the  heart  would  shorten  on  the  whole.  In 
the  actual  heart  both  sets  are  present,  and  they  conspire  as  to  the 
diminishing  of  the  cavity,  but  they  conflict  as  to  changing  the  length  of 
the  heart.  The  result  is,  on  the  one  hand,  increased  efficiency  in 
expelling  the  blood  ;  on  the  other,  a  balance  between  the  opposing 
forces  which  keeps  the  length  of  the  heart  unchanged.  This  latter 
balance  is  not  an  idle  refinement.  The  mutual  checking  and  restraining 
of  each  other's  play  calls  out  the  elasticity  as  well  as  the  contractility  of 
the  muscles.  In  systole  they  are  in  strained  equilibrium.  The  rd'sult 
is  that,  as  soon  as  the  effort  of  contraction  ceases,  the  elastic  action  will 
set  up  a  springlike  reaction,  and  the  ventricles  begin  to  dilate  actively. 


NORMAL   AND    ABNORMAL    HEART 


257 


,  .  .  Marey  and  Fick,  Goltz  and  Gaule,  .  .  .  have  shown  that  in  the 
beginning  of  diastole  there  is  such  an  active  element  in  the  dilatation." 

Appearances  seen   on  the  Fluorescent  Screen  to   the   Right   of   the 

Sternum The  appearances   seen  on   the   screen  to  the   left  of  the 

sternum  can  be  readily  interpreted,  but  those  on  the  right  border  of 
the  sternum  may  vary  in  different  individuals  and  may  sometimes  be 
quite  puzzling ;  therefore  to  properly  interpret  them  it  is  necessary  not 
only  to  carefully  study  them,  but  also  to  study  the  measurements  show- 
ing the  position  of  the  blood  vessels  and  the  right  auricle  and  ventricle 
during  expiration  and  full  inspiration. 

On  the  right  of  the  sternum  the  shadow  of  the  blood  vessels  may  be 
seen  in  expiration,  but  not  always  that  of  the  right  border  of  the  right 
ventricle. 

I  have  studied  the  position  of  the  blood  vessels  and  of  the  borders 
of  the  heart  at  autopsies  made  at  the  Boston  City  Hospital,  and  taken 
measurements  of  the  position  of  this  organ  after  death,  but  the  number 
observed  was  too  few  to  afford  a  basis  for  positiv-e  conclusions.  The 
measurements  obtained,  however,  show,  when  compared  with  the  appear- 
ances which  I  have  seen  on  the  fluorescent  screen,  that  the  position  of 
the  right  border  of  the  heart  with  reference  to  the  sternum  varies  in 
different  individuals,  and  also  under  different  pathological  conditions 
brought  about  by  disease  in  itself  or  in  neighboring  organs.  For 
instance,  in  a  man  who  died  of  arsenical  poisoning,  I  found,  after 
the  sternum  had  been  removed,  that  the  right  border  of  the  right  ventri- 
cle was  0.5  centimetres  to  the  right  of  the  median  line.  When  the  dia- 
phragm was  pulled  down,  the  right  border  of  this  ventricle  was  1.25 
centimetres  to  the  right  of  this  line.  It  probably  could  not  have  been 
seen  in  this  patient  even  in  full  inspiration.  The  border  of  the  superior 
vena  cava,  in  the  fourth  intercostal  space,  was  4.5  centimetres  to  the 
right  of  the  median  line  (its  shadow  could  have  been  seen),  and  the 
left  border  of  the  ventricle  was  9  centimetres  to  the  left  of  the  same 
line. 

Again,  at  the  autopsy  made  on  a  man  who  died  of  pneumonia,  I 
saw  that  the  right  ventricle  would  evidently  have  reached,  during  a  full 
inspiration,  much  beyond  the  right  of  the  sternum.  The  right  auricle 
extended  from  the  lower  border  of  the  second  rib  to  the  lower  border 
of  the  fifth  rib,  and  3.5  centimetres  to  the  right  of  the  median  line.  In 
the  case  of  a  patient  with  a  normal  chest,  that  I  had  examined  radio- 


258    THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

scopically  a  few  days  before  his  death,  and  on  whose  skin  the  outlines 
of  the  heart  still  remained,  I  found  that  the  heart  after  death  was  a 
little  higher  in  the  thorax  than  in  life.  These  instances  show,  there- 
fore, that  the  question  of  what  could  and  could  not  be  seen  on  the 
fluorescent  screen  should  be  carefully  studied,  and  measurements  taken 
at  autopsies  after  the  sternum  has  been  removed,  and  both  before  and 
after  the  pericardium  has  been  opened.  The  distance  from  the  median 
line  to  the  border  of  the  heart  is  readily  found  by  measuring  the 
distance  from  a  string  stretched  from  a  point  midway  between  the 
clavicles  to  the  pubes. 

We  have  been  observing  the  movements  of  the  normal  heart  with 
the  patient  lying  on  his  back  and  the  screen  on  the  front  of  the  chest ; 
a  better  position  for  an  examination  than  if  he  were  lying  on  his  face 
and  with  the  screen  on  his  back,  because  ordinarily  the  heart  is  nearer 
to  the  front  of  the  chest  than  to  its  back.  After  the  heart  has  been 
examined  with  the  patient  in  this  position,  he  may  be  turned  on  one 
side  or  the  other,  or  lie  on  his  face,  or  partly  on  one  side,  if  it  is  desired 
to  see  the  heart  from  different  directions.  The  physician  should  famil- 
iarize himself  with  the  outlines  of  this  organ  as  seen  when  the  patient 
is  placed  in  different  positions. 

If  the  patient  lies  on  his  right  side,  with  his  arms  held  forward  or 
up  so  that  they  will  not  be  in  the  way,  and  the  screen  be  applied  to  the 
left  side,  and  the  vacuum  tube  be  so  placed  that  the  light  is  opposite 
the  middle  of  the  right  side  and  the  lower  border  of  the  heart,  a  bright 
area,  usually  triangular  in  shape,  which,  so  far  as  I  am  aware,  was  iirst 
demonstrated  by  me,^  will  come  into  view  during  deep  inspiration.  This 
triangle  is  made  up  of  three  curved  lines,  the  lowest  being  the  outline 
of  the  diaphragm  ;  the  upper  and  anterior  one,  the  posterior  border  of 
the  heart ;  and  the  posterior  one  the  outlines  of  the  spine  or  of  the 
tissues  immediately  in  front  of  it.  This  triangle  is  usually  closed  at 
the  anterior  angle,  but  did  not  happen  to  be  in  the  patient  from  whom 
the  following  diagram  was  made.  The  outline  of  the  anterior  border 
of  the  heart  may  also  be  followed  in  some  patients,  as  well  as  much  of 
the  lower  and  posterior  border. 

Likewise,  when  the  patient  is  examined  with  the  light  going  through 
the  body  from  side  to  side,  a  space,  broad  above  and  narrower  below,  is 

1 "  X-Rays  in  Medicine,"  Transactions  of  the  Medical  Society  of  the  State  of  New  York, 
January,  1898. 


NORMAL   AND    ABNORMAL   HEART 


259 


seen  between  the  anterior  and  upper  portion  of  the  heart  and  the  chest 
wall.  This  area  is  seen  to  widen  and  lengthen  in  full  inspiration. 
That  is  to  say,  the  heart  moves  downward,  and  the  upper  portion 
slightly  backward,  as    more   lung  intervenes  between  the  upper   part 


\> 


C^ 


^ 


Fi<;.  158.  Triangle. 
The  outline  of  the  body  and  the  ends  of  the  ribs  have  been  traced  from  an  anatomical 
plate,  which  represents  a  section  of  the  body  through  the  left  parasternal  line.  The  heart  line  and 
the  outlines  of  a  portion  of  the  diaphragm  and  spine,  or  rather  what  lies  in  front  of  the  spine,  form  the 
triangle,  and  were  drawn  on  the  skin,  together  with  the  remaining  heart  lines,  while  looking  through 
the  patient  during  full  inspiration,  with  the  fluorescent  screen  placed  on  the  left  side.  These  lines 
were  then  transferred  to  the  drawing  from  which  this  cut  was  made.  The  outline  of  the  heart  is 
indicated  in  the  cut  partly  by  a  full  and  partly  by  a  dotted  line.  The  full  line  shows  the  extent 
of  the  lower  and  posterior  border  usually  seen  in  health  on  the  fluorescent  screen ;  the  dotted  line,  the 
additional  amount  seen  in  this  individual  in  health. 

of  the  heart  and  the  front  chest  wall  than  between  the  lower  part  of 
this  organ  and  this  chest  wall.  I  observed  this  movement  and  the 
consequent  increasing  of  the  above-mentioned  space  very  well  in  one 
of  my  patients,  J.  H.,  a  well-built  man  twenty  years  of  age,  who  was 


26o    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

convalescent  from  typhoid  fever.  This  distance  of  the  heart  from  the 
chest  wall  would  prevent  an  accurate  determination  of  the  upper  bor- 
ders of  this  organ  by  percussion,  especially  in  full  inspiration.  (See 
chapter  on  Emphysema,  page  198.) 

The  width  of  the  dark  area  which  is  back  of  the  sternum  and  above 
the  heart  varies  with  the  position  of  the  patient;  it  is  a  Httle  wider 
when  he  is  lying  down  than  when  he  is  sitting,  and  in  expiration  than 
in  deep  inspiration.  The  width  of  the  heart  also  varies  in  like  manner 
and  from  the  same  cause.  The  heart  and  blood  vessels  are  farther  away 
from  the  screen  when  the  patient  is  lying  than  when  he  is  sitting  down, 
and  therefore,  for  optical  reasons,  the  dark  area  alluded  to,  and  the 
heart,  cast  a  broader  shadow  on  the  screen  when  he  is  in  the  former 
than  in  the  latter  position.  This  difference  in  width,  however,  may  be 
neglected  for  clinical  purposes,  if  the  source  of  light  is  at  the  proper 
distance  from  the  patient. 

Width  of  Normal  Heart.  —  I  found  the  average  width  of  the  heart, 
as  determined  by  an  X-ray  examination  of  forty-eight  men,  was  3  centi- 
metres from  the  median  line  to  the  right  border,  and  8.6  centimetres 
from  the  median  line  to  the  left  border;  total  11.6  centimetres.  In 
thirty-one  women  the  width  was  2.5  centimetres  from  the  median  line 
to  the  right  border,  and  8.7  centimetres  from  the  median  line  to  the 
left  border;  total  11.2  centimetres.  These  cases  indicate  that  the 
heart  in  women  lies  a  little  more  to  the  left  than  in  men,  but  these 
observations  are  of  course  too  few  and  too  incomplete  for  definitely 
determining  the  average  width  of  the  heart. 

It  is  important  not  only  to  obtain  the  size  of  the  heart  as  a  whole, 
but  also  the  size  of  the  right  heart  as  compared  with  that  of  the  left ; 
and  we  must  always  bear  in  mind  the  conditions  which  may  draw  the 
heart  in  one  or  another  direction,  or  push  it  one  way  or  another.  This 
point  will  be  taken  up  later. 

If  we  note  carefully  the  width  of  the  heart  on  the  right  side  of  the 
median  line,  as  well  as  of  that  on  the  left  side,  and  the  total  width, 
we  may  infer  from  these  figures  whether  or  not  the  heart  is  displaced 
or  one  side  is  more  enlarged  than  the  other. 

Location  of  the  Right  and  Left  Borders  of  the  Heart  by  Distance  from 
the  Median  Line.^ — The  determination  of  the  right  and  left  borders  of 
the   heart  by  the    distance  from   the   median   line   is  a  more  accurate 

1  "  Location  of  the  Right  and  Left  Borders  of  the  Heart  by  the  Distance  from  the  Median 
Line,"  by  F.  H.  Williams,  M.D.,  Boston  Medical  and  Surgical  Journal,  June  21,  1899. 


NORMAL   AND   ABNORMAL   HEART 


261 


method  than  the  one  now  generally  used,  of  designating  its  left  border 
by  reference  to  the  nipples,  and  its  right  border  by  reference  to  the 
sternum.  In  women  the  nipple  line  is  too  indefinite  to  be  considered, 
and  in  men  the  position  of  the  nipples  varies  considerably ;  for  in- 
stance, in  21  men  in  one  of  my  wards  at  the  Boston  City  Hospital, 
the  distance  between  the  nipples  averaged  21.5  centimetres;  the  short- 
est distance  was  18.5,  the  longest  25.5  centim.etres.  In  other  words, 
in  21  patients  the  variation  between  the  extremes  was  7  centimetres 
from  nipple  to  nipple,  or  3.5  between  the  median  and  the  nipple  lines. 
Thus  we  see  that  the  position  of  the  nipples  may  vary  in  their  distance 
from  the  median  line  by  more  than  2.5  centimetres.  Such  a  variation 
in  the  size  of  the  heart  as  this  might  mean  serious  disease.  The  state- 
ment that  the  left  border  of  the  heart  is  a  little  inside  the  nipple  line 
would  not  strike  us  so  forcibly  as  if  we  were  told  that  it  was  2.5  centi- 
metres farther  to  the  left  than  in  health.  Moreover,  if  we  determine 
the  right  border  of  the  heart  as  so  many  centimetres  or  inches  to  the 
right  of,  and  the  left  border  as  so  many  centimetres  or  inches  to  the  left 
of,  the  median  line,  we  determine  not  only  how  much  it  is  to  the  right  or 
to  the  left,  but  by  adding  the  two  quantities  together  we  readily  get  the 
total  width  of  the  heart.  The  width  cannot  be  obtained  so  accurately 
when  the  right  border  is  determined  with  reference  to  the  sternum,  and 
the  left  border  with  reference  to  the  nipples. 

Width  of  Heart  in  Relation  to  Height  of  Individual  —  Levy-Dorn 
("Zur  Untersuchung  des  Herzens  mittels  Roentgenstrahlen,"  Verhand- 
lungen  des  Congresses  fur  Innere  Medicin,  1899)  measured  the  size  of 
the  heart  in  twenty-four  individuals  by  means  of  the  X-rays,  and  deter- 
mined what  its  normal  diameter  should  be  with  reference  to  the  height 
of  these  individuals.     The  following  table  shows  his  results  :  — 


1.25 

'•5 

1-75 


Heicht. 


metres, 
metres, 
metres. 


Diameter  ok  Heart. 


9 
II 
12 


centimetres, 
centimetres, 
centimetres. 


If  the  diameter  of  the  heart  is  considerably  greater  or  less  than  the 
figures  given,  Levy-Dorn  considers  it  indicative  of  pathological  condi- 
tions. 


262     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Abnormal  Heart.  —  When  the  heart  is  in  an  abnormal  condition, 
we  may  sometimes  obtain  a  more  complete  outline  of  it  on  the  fluores- 
cent screen  than  when  it  is  normal.  A  much-distended  right  auricle 
may  be  seen  if  the  lungs  are  clear,  but  it  frequently  happens  that  when 
this  auricle  is  much  distended  the  circulation  in  the  lungs  is  such  that 
the  contrast  between  the  shadow  of  the  pulmonary  area  and  the  auricle 
is  not  sufficiently  marked  to  enable  the  physician  to  distinguish  between 
the  former  and  the  latter  on  the  screen.  On  the  other  hand,  if  emphysema 
is  present,  the  lung  is  unusually  permeable  by  the  rays,  and  there  may  be  a 
good  opportunity  to  note  the  size  and  follow  the  pulsations  of  a  distended 
right  auricle.  The  left  auricle  might,  I  think,  be  seen  under  unusual  con- 
ditions if  it  were  very  much  distended.  In  examining  the  heart  the 
physician  should  note  carefully  whether  or  not  either  ventricle  is 
enlarged,  or  if  the  right  auricle  is  dilated ;  also  whether  or  not  the 
heart  changes  its  position  during  full  inspiration  and  what  the  changes 
are.  In  estimating  the  enlargement  of  the  heart,  the  observer  should 
not  only  consider  the  increase  in  the  transverse  diameter,  but  also  how 
much  the  relations  between  the  lower  border  of  the  heart  and  the 
diaphragm  differ  from  those  found  in  health.  In  the  latter  condition 
there  is  ordinarily  a  free  space  between  this  organ  and  the  muscle 
during  deep  inspiration.  The  heart  is  then  supported  by  the  blood 
vessels  and  does  not  rest  on  the  diaphragm. 

The  lateral  borders  of  the  dark  area  above  the  heart  are  cast  by  the 
blood  vessels  and  soft  tissues  which  lie  between  the  backbone  and  the 
sternum,  and  in  drawing  the  outlines  seen  on  the  screen  we  should  note 
with  care  their  lines.  Here  we  get  changes  in  outline  due,  for  example,  to 
the  beginning  of  an  aneurism  or  some  new  growths,  but  more  frequently 
to  a  deviation  towards  one  side  or  the  other,  the  consequence  of  dis- 
placement by  fluid  in  the  opposite  dark  side  of  the  thorax;  or,  if  the 
heart  is  drawn  toward  the  darker  side,  the  displacement  may  be  due  to 
contraction  of  the  lung  or  pleura  on  that  side. 

I  have  made  some  hundreds  of  tracings  of  heart  outlines  in  various 
diseases,  which  indicate  not  only  the  size  and  position,  but  also  the 
mobility  of  this  organ. 

By  the  use  of  an  instrument  which  I  have  devised,^  it  is  possible 
to  listen  to  the  heart's  sounds  while  the  movements  of  the  heart  are  fol- 
lowed on  the  screen.  A  better  form  of  this  instrument  has  been  devised 
by  Dr.  RoUins.     (See  Chapter  III,  page  60.) 

1  Boston  Medical  and  Surgical  Journal,  October,  1896. 


METHODS   OF   EXAMINATION  263 

SECTION    II 
METHODS    OF    EXAMINATION 

Intensity  of  Light.  —  In  examining  the  heart  with  the  fluorescent 
screen,  the  Hght  should  be  of  suitable  intensity,  neither  too  bright  nor 
too  faint,  as  in  either  case  the  borders  of  the  heart  would  be  ill  defined. 
In  young  people  special  care  must  be  taken  that  the  light  is  not  brighter 
than  necessary,  for,  if  too  bright,  not  merely  will  the  borders  of  the  heart 
become  indistinct,  but  the  whole  organ  will  cast  no  shadow. 

Position  of  Patient.  — When  a  patient  is  to  be  examined,  the  position 
in  which  he  is  placed  should  be  carefully  noted,  so  that  he  may  assume 
it  again  exactly  in  case  a  second  examination  is  desired  for  purposes  of 
comparison.     (See  Chapter  III.) 

Recumbent  and  Sitting  Position. — The  patient  may  be  examined 
either  lying  down  or  sitting  up  ;  in  some  cases,  as  stated  in  Chapter  III, 
the  latter  position  is  preferable  because  the  patient  cannot  lie  down  with 
comfort  owing  to  the  diseased  condition  of  his  heart.  The  arrangements 
for  an  examination  in  this  position  have  been  given  in  Chapter  III. 

Errors  to  be  avoided  in  measuring  the  Width  of  the  Heart.  —  In  exam- 
ining the  heart  for  the  purpose  of  measuring  its  width,  there  are  two 
sources  of  error  in  technique  to  be  avoided  ;  first,  that  which  would 
result  from  the  unsuitable  position  of  the  tube ;  and  second,  from  the 
manner  of  recording  the  outlines. 

Position  of  Tube.  —  The  tube  must  be  at  a  considerable  distance  (70 
to  75  centimetres)  from  the  heart  in  order  to  avoid  an  exaggeration  of  its 
shadow  on  the  screen.  If  the  heart  is  much  enlarged,  the  tube  should  be 
placed  directly  under  the  left  border  when  that  is  being  determined,  and 
moved  to  a  position  immediately  under  the  right  border  when  that  is  to 
be  obtained.  (See  Chapter  III,  page  62.)  These  positions  may  be  deter- 
mined by  the  use  of  the  indirect  plumb-line  already  described.  The 
change  in  the  position  of  the  tube  prevents  the  exaggeration  in  size 
which  would  otherwise  result.  In  a  normal  heart  this  change  is  not 
necessary,  as  the  slight  exaggeration  that  is  caused  by  determining  the 
right  and  left  borders  with  the  tube  in  the  same  position  can  be  just 
about  neutralized  by  drawing  the  outline  of  the  heart's  border  on  the 
inner  side  of  the  shadow  instead  of  on  the  outer  side. 

Position  of  Screen.  —  If  the  patient  to  be  examined  is  stout,  or  is  a 
woman  with  well-developed  breasts,  so  that  the  screen  must  be  at  some 


264     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

distance  from  the  heart,  the  size  of  this  organ,  especially  on  its  left 
border,  will  be  exaggerated,  that  is  to  say,  the  shadow  will  fall  too  far  to 
the  left.  Therefore  in  such  cases  also  the  tube  must  be  placed  directly 
under  the  border  to  be  determined,  and  this  point  may  be  obtained  by 
means  of  the  indirect  plumb-line  already  described. 

Tracings  on  the  Skin.  —  If  the  outline  of  the  left  border  of  the  heart 
when  marked  on  the  skin  is  in  about  the  same  plane  as  the  sternum,  its 
distance  from  the  median  line  can  be  measured  correctly  ^  by  stretching 
a  tape  measure  along  the  skin  from  the  median  line  to  this  point,  but  if 
the  outline  of  the  left  border  falls  so  far  to  the  left  that  the  tape-meas- 
ure, in  following  the  skin,  must  go  around  to  the  side  of  the  chest,  it  is 
evident  that  the  measurement,  so  taken,  from  the  median  line  to  this 
point  would  be  too  great.  To  avoid  this  source  of  error,  one  end  of  the 
tape-measure  should  be  held  at  the  median  line  and  the  measure  be  then 
drawn  out  horizontally,  and  the  left  border  marked  upon  it  at  the  point 
where  this  outline  of  the  heart  would  fall  when  projected  upon  the 
measure  at  right  angles  to  it. 

A  similar  course  must  be  pursued  under  similar  circumstances  if  the 
outlines  traced  upon  the  skin  are  retraced  on  tracing  cloth  ;  for  if  the 
cloth  were  folded  around  the  chest  and  the  heart  were  so  enlarged  or 
displaced  that  the  outline  of  the  left  border  fell  upon  the  curved  por- 
tion of  the  cloth,  the  width  of  the  heart  measured  upon  the  cloth  would 
be  greater  than  the  reality.  Therefore,  to  avoid  this  exaggeration,  the 
cloth,  like  the  tape-measure,  must  be  held  in  a  horizontal  plane  and  the 
line  already  drawn  upon  the  skin  be  projected  upon  the  cloth. 

The  size  of  the  heart  would  be  exaggerated  under  similar  circum- 
stances if  the  line  of  the  skin  were  followed  from  the  median  line  to  the 
left  border,  in  making  a  measurement  of  the  width  as  determined  by 
percussion. 

Tracings  on  a  Thin  Sheet  of  Glass  or  a  Film  of  Celluloid.  —  If,  instead 
of  tracing  the  outlines  of  the  heart  directly  upon  the  skin,  we  put  over 
the  screen  a  thin  sheet  of  glass  or  a  transparent  film  of  celluloid,  and 
draw  them  upon  this  glass  or  film,  as  the  case  may  be,  the  shadow  of  the 
heart  would  be  projected  upon  a  horizontal  plane,  and  the  error  just 
referred  to  would  be  avoided.  The  disadvantage  of  this  method  is  the 
fact  that  it  is  not  easy  by  its  use  to  determine  the  median  line,  but  this 
difficulty  can  be  overcome  by  the  means  described  in  Chapter  III. 

'  The  error  caused  by  the  position  of  the  diaphragm  is  taken  up  later  in  this  section  and  ia 
Section  IV. 


METHODS   OF    EXAMINATION  265 

Comparison  of  Tracing  Cloth  with  Glass  or  Celluloid  Film.  —  As  most 
of  the  measurements  in  the  chest  which  require  accuracy  are  those  about 
the  heart,  and  as  in  most  cases  these  Hnes  fall  upon  the  front  of  the 
chest,  I  think  as  a  general  rule  the  more  practical  way  is  to  draw  the 
outlines  upon  the  skin  and  then  copy  them  carefully  on  to  tracing  cloth, 
the  line  of  the  heart  being  projected  on  the  cloth  if  it  falls  too  far  to  the 
left  to  allow  the  cloth  to  remain  close  to  the  chest  and  yet  be  in  a 
horizontal  plane. 

The  tracings  given  below  and  belonging  to  the  following  case,  illus- 
trate two  of  the  sources  of  error  which  must  be  guarded  against  in  meas- 
uring the  width  of  the  heart :  first,  that  caused  by  a  faulty  manner 
of  recording  the  outlines  on  the  tracing  cloth  ;  and  second,  that  due  to 
the  position  of  the  diaphragm.  They  also  indicate  that  points  of  refer- 
ence on  the  tracing  cloth  or  film  are  necessary  in  order  to  avoid  the 
error  that  might  otherwise  arise  if  a  comparison  were  made  between  the 
widths  of  the  heart  of  a  given  individual  determined  at  different  periods 
of  time. 

M.  C,  fifty-three  years  old.  Patient  of  Dr.  H.  D.  Arnold  at  the  out- 
patient department  of  the  Boston  City  Hospital. 

Family  History.  —  One  brother  and  one  sister  died  of  phthisis. 

Present  Illness.  —  Distress  and  soreness  in  praecordial  region,  with 
dyspnoea  and  sense  of  suffocation,  worse  at  night,  for  two  or  three 
weeks.  Palpitation.  Feet  cold  and  swell  at  times.  Deep  breathing 
causes  pain  followed  by  sense  of  relief. 

Jamiary  17.  Physical  Examination.  —  Arteries  very  markedly  scler- 
otic ;  pulse  regular  and  of  moderate  rate  and  low  tension.  Heart  impulse 
seen  widely  diffused  ;  apex  in  sixth  interspace  about  2  centimetres  out- 
side nipple.  Heart  flatness  begins  about  top  of  fourth  rib  and  extends 
to  right  border  of  sternum.  At  apex  is  heard  a  systolic  murmur  of  great 
intensity,  which  is  transmitted  to  back,  entirely  replaces  first  sound,  and 
at  apex  no  second  sound  is  heard.  The  murmur  can  be  heard  everywhere 
throughout  the  praecordial  area  and  also  in  neck.  At  base,  second 
pulmonic  was  markedly  accentuated. 

February  11.  Thorough  and  detailed  examination  by  Dr.  Arnold  at 
the  out-patient  department  of  the  Boston  City  Hospital.  Venous  and 
subclavian  pulse  while  lying  down,  disappears  on  sitting.  Murmur  as 
before. 

I  examined  this  patient  with  the  fluorescent  screen  on  February  1 1 
and  March  25,  1899,  and  March  i,  1900,  and  the  results  of  these  X-ray 


266     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

examinations  may  be  seen  in  the  following  figures  which  were  made 
from  tracings  taken  from  the  patient's  chest  on  the  dates  given 
above.  In  all  of  these  tracings  the  borders  of  the  heart  obtained  by 
the  X-ray  examination  are  indicated  by  full  lines,  and  those  deter- 
mined  by  percussion   by  dotted   lines,  except  in  the  third  tracing,  in 


Fig.  159.  M.  C.  First  X-ray  tracing  (one-third  life  size).  Cardiac.  The  dotted  line  indicates 
the  cardiac  outline  as  determined  by  percussion  ;  the  full  line  (except  of  course  the  median  line 
and  the  curve  indicating  the  suprasternal  notch)  and  the  broken  lines,  the  outlines  of  the  heart  and 
diaphragm  as  obtained  by  the  X-rays.  The  outer  full  line  on  the  left  indicates  the  position  of  the 
heart  in  expiration ;  the  inner,  in  full  inspiration.  The  distance  between  the  median  line  and  the  left 
border  of  the  heart  as  obtained  by  the  X-ray  examination  is  slightly  exaggerated,  owing  to  the  manner 
in  which  the  outlines  are  recorded  on  the  tracing  cloth.    The  error  is  still  greater  by  percussion. 


which  the  line  obtained  by  percussion  for  the  left  border  is  the  same  as 
that  by  the  uncorrected  X-ray  line,  and  therefore  only  one  line  is  given. 
The  agreement  in  these  two  Hues  may  be  the  result  of  the  position  of 
the  heart  with  regard  to  the  chest  wall,  for  when  this  organ  is  more 
nearly  in  contact  with  this  wall,  a  larger  portion  of  its  border  can  be 


METHODS   OF   EXAMINATION 


267 


determined   by  percussion   than   usual,  and   therefore   by  this    method 
the  width  seems  increased. 

These  tracings  are  given  to  call  attention  to  a  faulty  method  of  meas- 
uring the  width  of  the  left  side  of  the  heart  by  the  X-rays  (Figs.  159 
and   160). 


MtTjrch  2J^  IS99 


© 


Fig.  160.  M.  C.  Second  X-ray  tracing  (one-third  life  size).  The  dotted  line  indicates  the  car- 
diac outline  as  determined  by  percussion  ;  the  full  line  (exxept  of  course  the  median  line  and  the  curve 
indicating  the  suprasternal  notch)  and  the  broken  lines,  the  outlines  of  the  heart  and  diaphragm  as 
obtained  by  the  X-rays.  The  outer  full  line  on  the  left  indicates  the  position  of  the  heart  in  expiration  ; 
the  inner,  in  full  inspiration.  The  distance  between  the  median  line  and  the  left  border  of  the  heart 
as  obtained  by  the  X-ray  examination  is  slightly  exaggerated,  owing  to  the  manner  in  which  the 
outlines  are  recorded  on  the  tracing  cloth.     The  error  is  still  greater  by  percussion. 

Figure  161  illustrates  the  result  of  a  faulty  method  of  measuring 
the  left  border  of  the  heart  by  the  X-rays,  but  more  especially  the 
difference  obtained  between  the  width  of  the  heart  when  it  is  measured 
with  the  diaphragm  higher  up  in  the  chest  than  normal,  and  the  width 
determined  when  the  diaphragm  is  in  its  natural  position. 

Position  of  Tracing  Cloth.  —  In  these  tracings  the  cloth  was 
wrapped  round  the  chest,  and  therefore  the  width  of  the  heart  between 


268    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

the  median  line  and  the  left  border  is  slightly  exaggerated  in  the  two 
first  tracings,  and  very  much  so  in  the  third  tracing.  The  greatest 
exaggeration  is  found  in  this  latter  case  because  the  left  border,  on 
account  of  the  more  horizontal  position  of  the  heart  obtaining  at  this 


March  i^t.  /aoo 


Fig.  i6i.  M.  C.  Third  X-ray  tracing  (one-third  life  size).  The  short  vertical  line  below  the  left 
nipple  indicates  the  distance  of  the  left  border  of  the  heart  from  the  median  line  measured  in  a  plane 
parallel  with  the  front  of  the  chest,  by  means  of  the  X-rays;  the  curved  lines  its  too  great  distance 
when  the  outline  is  traced  on  the  cloth  where  it  lies  folded  around  the  body.  The  line  by  percussion 
coincides  with  this  latter  line,  and,  like  it,  is  in  error. 

As  compared  with  the  previous  examinations,  the  heart  is  increased  in  width.  The  diaphragm 
is  now,  however,  higher  in  the  chest  than  before,  and  the  long  axis  of  the  heart  is  therefore  more  hori- 
zontal. Another  examination,  with  the  diaphragm  lower  down  in  the  chest,  would  be  necessary  in 
order  to  have  the  lines  obtained  at  this  examination  comparable,  as  to  the  width  of  the  heart,  with 
those  determined  at  the  preceding  ones.  The  position  of  the  ri^kt  border  of  the  heart  by  percussion 
is  shown  by  the  dotted  line. 


examination,  and  perhaps  greater  enlargement  falls  farther  to  the  left 
than  at  the  two  former  examinations,  and  therefore  the  tracing  cloth  went 
farther  round  the  chest.  It  is  evident  that  the  farther  the  cloth  must 
curve  round  the  chest  to  reach  the  left  border  of  the  heart,  the  longer 
will  be  the  line  following  the  skin  which  extends  from  the  median  line 


METHODS   OF    EXAMINATION  269 

to  the  point  marking  this  left  border,  and  the  more  will  it  differ  from 
the  line  giving  the  width  of  the  heart  when  measured  in  a  horizontal 
plane ;  therefore  the  error  arising  from  measuring  the  heart  by  folding 
the  tracing  cloth  round  the  chest  increases  as  the  left  border  of  the 
heart  falls  farther  to  the  left.  The  third  tracing  best  illustrates  the 
error  made  by  the  improper  position  of  the  tracing  cloth.  The  width 
of  the  heart  between  the  median  Une  and  its  left  border,  which  extends 
beyond  the  nipple  Hne  in  expiration,  is  13.5  centimetres,  but  the  width 
obtained  by  holding  the  cloth  in  a  horizontal  plane,  as  already  de- 
scribed, and  projecting  the  left  border  upon  it,  is  12  centimetres;  that 
is  to  say,  the  difference  in  the  width  due  to  the  two  positions  of  the 
tracing  cloth  is  1.5  centimetres.  The  heart  is  also  wider  than  normal 
in  this  tracing  apart  from  its  possible  enlargement,  on  account  of  the 
position  of  the  diaphragm,  as  stated  below. 

Error  Greater  by  Percussion.  —  These  diagrams  also  show  that  in 
determining  the  width  of  the  heart,  not  only  by  X-ray  examination  but 
also  by  percussion,  we  must  measure  the  distance  from  the  median  line 
in  a  plane  parallel  with  the  front  of  the  chest,  and  not  from  the  median 
line  around  the  chest.  This  source  of  error  is  not  one  which  is  special 
to  X-ray  examinations.  It  will  be  observed  in  two  of  the  tracings  that 
the  error  made  by  folding  the  cloth  around  the  chest  and  then  tracing 
the  outlines  of  the  left  border  of  the  heart,  as  seen  by  the  X-rays,  upon 
it,  was  not  so  great  as  that  made  by  percussion. 

Position  of  Diaphragm.  —  If  these  tracings  are  compared  it  will  be 
seen  that  the  width  of  the  heart  is  much  greater  in  the  tracing  made  in 
March,  1900  (the  third  X-ray  examination),  than  in  the  other  two. 
This  greater  width  may  be  partially  due  to  increase  in  size,  but  two  other 
causes  certainly  are  concerned.  The  first  is  the  position  of  the  dia- 
phragm. This  muscle  was  higher  up  in  the  chest  when  the  third  trac- 
ing was  made  than  when  the  previous  ones  were  drawn,  and  the  axis  of 
the  heart  was  therefore  more  horizontal  (see  Section  IV);  the  second 
is  the  position  of  the  tracing  cloth. 

Points  of  Reference.  —  These  tracings  also  call  attention  to  the 
necessity  of  the  points  of  reference,  for  if  the  tracings  had  been  made 
on  a  transparent  film  placed  above  the  fluorescent  screen,  and  the  nip- 
ples and  sternal  notch  had  not  been  indicated  on  the  tracing  cloth  when 
held  horizontally  on  the  chest,  another  error  referred  to  above  (see 
page  265)  would  have  arisen.  That  is,  when  the  lines  shown  on  the 
third  tracing  were  compared  with  those  of  the  other  two,  the  change  in 


270     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

width  noted  might  have  been  ascribed  as  wholly  due  to  enlargement  of 
the  heart,  but  for  the  nipples  as  points  of  reference,  whereas,  with 
these,  it  is  clear  that  the  diaphragm  was  higher  and  the  axis  of  the 
heart  more  horizontal  in  the  tracing  made  in  March,  1900,  than  in  those 
made  in  1899. 

Photograph  of  Heart.  —  A  photograph  of  the  heart,  taken  during 
full  inspiration,  gives  a  definite  outline  and  leaves  no  room  for  doubt  in 
regard  to  the  trustworthiness  of  the  X-ray  determinations  of  the  borders 
of  the  heart,  if  these  are  made  under  suitable  conditions  and  with 
proper  precautions.  The  photograph  is  best  made  during  a  deep  inspi- 
ration as  already  stated. 

Comparative  Value  of  Radiograph  and  Screen  in  Examinations  of  the 
Heart.  — The  photographic  methoci  is  not  so  satisfactory  as  the  screen 
for  examinations  of  the  heart,  for  the  pulsations  blur  the  outline  in  the 
photograph  somewhat,  and  the  changes  in  position  during  different 
stages  of  respiration  cannot  be  studied  by  this  method  as  on  the  screen. 
Further,  time  is  necessary  to  take  a  photograph  and  develop  it,  and 
this  delay  prevents  the  physician  from  gathering  directly  the  results  of 
all  the  different  methods  of  examination  for  the  purposes  of  diagnosis. 


SECTION    III 

THE  IMPORTANCE  OF  KNOWING  THE  SIZE  OF  THE  HEART.  INAC- 
CURACY OF  PERCUSSION  IN  DETERMINING  ITS  SIZE  AS  SHOWN 
BY   X-RAY    EXAMINATIONS 

In  cardiac  diseases  the  size  of  the  heart  is  of  the  utmost  importance, 
not  only  in  diagnosis,  but  also  in  prognosis. 

Prognosis.  —  If,  for  example,  we  find  by  examining  the  heart  from 
time  to  time  that  its  size  is  increasing,  and  that  this  enlargement  is  due  to 
dilatation,  the  prognosis  would  be  unfavorable.  If,  on  the  other  hand, 
we  find,  especially  in  the  acute  forms  of  relaxation  of  the  cardiac  walls 
from  overwork,  overstrain,  etc.,  that  the  size  of  the  heart  is  diminish- 
ing under  rest  and  suitable  remedies,  we  have  additional  evidence  on 
which  to  base  a  favorable  prognosis.  It  is  important  to  know  the  size 
of  the  heart  as  a  whole,  as  well  as  the  size  of  the  right  heart  as  compared 
with  the  left,  as  already  stated  ;  it  is  also  important  to  watch  changes 
going  on  in  the  left,  —  and  in  the  right  side  of  the  heart  so  far  as  may 
be,  —  to  observe  the  increase  of  this  organ  brought  about  by  the  insuf- 


THE    SIZE    OF   THE    HEART  271 

ficiency  in  the  valves  due  to  the  relaxation  of  the  circular  fibres  about 
the  auriculo-ventricular  opening  on  one  side,  or  the  papillary  muscles 
on  the  other,  which  gives  rise  to  murmurs  that  may  cease  when  the 
heart  approaches  more  nearly  the  normal  size  again. 

Diagnosis.  —  In  the  minds  of  many,  cardiac  enlargement  is  chiefly 
associated  with  valvular  disease,  but  there  are  other  causes  acting  out- 
side the  heart  which  may  give  rise  to  an  increase  in  the  size  of  this  organ. 
A  murmur  is  to  some  pathognomonic  of  heart  disease  ;  but  this  indication 
is  not  to  be  wholly  relied  upon,  for  we  may  of  course  have  murmurs 
without  organic  cardiac  disease,  and  cardiac  disease  without  murmurs. 

If  the  heart  is  larger  than  normal,  we  have  an  indication  of  disease 
which  has  its  origin  either  inside  or  outside  of  the  heart ;  except,  of 
course,  in  those  cases  in  which  physiological  hypertrophy  exists  as  a 
result  of  athletics,  or  of  the  excessive  amount  of  work  entailed  by  some 
occupations.  On  the  contrary,  if  the  size  is  normal,  it  is  not  probable 
that  any  serious  chronic  lesion  of  the  valves  is  present  in  a  young 
person. 

It  is  also  important  to  know  when  the  heart  is  smaller  than  normal, 
for  those  persons  whose  hearts  are  not  as  large  as  the  body  demands 
should  avoid  pursuits  and  exercises  beyond  their  strength.  With  the 
usual  means  of  examination  a  small  heart  is  frequently  overlooked. 

A  brief  reminder  of  some  of  the  conditions  in  which  the  size  of 
the  heart  departs  from  that  found  in  health  is  in  place  here,  since  the 
importance  of  knowing  its  size  may  be  best  appreciated  by  considering 
the  conditions  under  which  this  occurs.  I  shall  exclude  from  this 
category  the  acute  changes  in  the  size  of  the  heart  which  may  accom- 
pany excessive  exercise,  or  acute  diseases  such  as  pneumonia,  or  acute 
dilatation  of  the  heart. 

The  chief  causes  of  enlarged  heart  may  be  divided  into  two  groups  : 
first,  those  acting  from  within  the  heart  wall ;  second,  those  from  with- 
out. In  this  first  group,  according  to  Howard,  are  valvular  lesions,  and, 
of  less  frequent  occurrence,  fatty  heart,  tuberculosis,  and  aneurism  of 
the  heart. 

In  the  second  group,  causes  originating  outside  of  the  heart  are  in 
the  order  of  their  frequency  :  — 

Arterio-sclerosis.  Pericardial  adhesions. 

Nephritis.  Excessive  work. 

Alcoholic  intemperance. 
Tumors  (pressing  on  vascular  trunks). 


272 


THE    ROENTGEN    RAVS   IN    MEDICINE    AND    SURGERY 


Causes  involving  enlargement  of  the  right  side  of  the  heart  are 
obstructions  in  the  pulmonary  circulation,  and  these  are  found  in  various 
pulmonary  diseases,  especially  emphysema. 

The  recognition  of  an  enlarged  heart  may  not  only  warn  us  of  the 
presence  of  an  otherwise  unsuspected  valvular  lesion,  arterio-sclerosis,  or 
chronic  nephritis,  but  if  its  borders  are  well  determined  they  may  also 
assist  us  in  recognizing  the  gravity  of  the  conditions  causing  the  enlarge- 
ment, and  careful  determinations  of  the  size  of  the  right  and  left  ven- 
tricles may  aid  us  in  prognosis. 

Let  us  now  consider  whether  or  not  our  present  methods  enable  us 
to  determine  the  size  of  the  heart  with  accuracy. 

Comparison  of  Percussion  and  X-Ray  Examination.  —  In  a  considerable 
number  of  cases  which  I  have  examined  during  the  past  five  years,  I 
first  determined  the  borders  of  the  heart  by  percussion  and  recorded 
these  outlines  on  the  skin  with  a  blue  pencil,  and  then  determined  the 
outline  of  the  heart  by  an  X-ray  examination  and  drew  these  outlines 
with  a  black  crayon.  On  comparison  of  these  two  sets  of  lines  I  was 
much  struck  by  their  frequent  discrepancy  in  either  one  or  more  borders 
of  the  heart,  and  by  the  greater  completeness  of  the  cardiac  outlines  as 
obtained  by  X-ray  examination. 

Width  of  Heart  obtained  by  Percussion  compared  with  Weight  of 
Heart  obtained  at  Autopsy.  —  It  occurred  to  me  to  test  still  further  the 
accuracy  of  the  determination  by  percussion  of  the  right  and  left  bor- 
ders of  the  heart,  by  comparing  the  widtJi  of  the  heart  as  found  in  the 
clinical  record  with  the  zvcigJit  of  the  heart  as  determined  by  the  post- 
mortem examination.  —  It  is  obvious  that  this  method  of  comparison 
may  err,  for  a  heart  may  be  so  distended  during  life  as  to  give  a  large 
cardiac  area  to  percussion,  although  it  may  not  weigh  much  more  than 
normal.  On  the  other  hand,  if  the  weight  of  the  heart  is  much  increased, 
it  must  have  been  enlarged  during  life. — With  this  end  in  view  I 
attempted  to  compare  the  size  of  the  heart  in  one  thousand  patients  as 
found  by  percussion  and  given  in  the  clinical  records  of  the  Boston 
City  Hosi)ital,  with  its  weight  as  found  in  one  thousand  consecutive 
autopsies,  including  both  medical  and  surgical  cases.  For  the  use  of 
the  autopsy  records  I  desire  to  thank  Dr.  W.  T.  Councilman,  under 
whose  direction  the  pathological  department  of  the  hospital  is  con- 
ducted. 

Four  JuDidrcd  and  fifty-four  cases  were  not  used  for  the  following 
reasons : — 


THE    SIZE    OF   THE    HEART  273 

1.  The  patients  were  under  twenty  years  of  age. 

2.  No  heart  weights  were  given. 

3.  The  records  were  incomplete. 

4.  The  patients  had  emphysema,  or  were  stout,  and  in  these  cases 
pcrcHssiou  is  at  a  great  disadvantage. 

Five  JuiJidrcd  mid  forty-six  cases  were  used. 

The  average  weights  of  hearts,  as  determined  by  Dr.  H.  D.  Arnold 
at  the  Boston  City  Hospital,  is  290  grammes  for  men  and  260  grammes 
for  women.  I  have  divided  the  546  cases  (370  men  and  176  women,  the 
men  and  women  being  classed  separately)  into  six  groups  each,  accord- 
ing to  their  weight,  as  will  be  seen  in  the  following  table,  marked  A  :  — 

^.  — HEART  WEIGHTS    CO.MPARED    WITH   HEART  WIDTHS 

AIkn.     Average  Weight  in  Health  290  Grammes 

Croup  I.  —  Weights  below  225  grammes.     Nine  cases. 
7.  area  normal  by  percussion. 

I.  area  enlarged  by  percussion.     Small  size  not  recognized  in  88  %. 

Group  IL  — Weights  225-349  grammes.     One  hundred  and  sixty-eight  cases. 

II,  area  diminished  by  percussion. 

Group  III. — Weights  350-399  grammes.     Seventy-four  cases. 
56,  area  normal  by  percussion. 
6.  area  diminished  by  percussion.     No  enlargement  recognized  in  83  %. 
Group  IV.  — Weights  400-449  grammes.     Twenty-six  cases. 
1 5.  area  normal  by  percussion. 
I,  area  diminished  by  percussion.     No  enlargement  recognized  in  61  %. 
Group   V.  —  Weights  450-499  grammes.     Twenty-four  cases. 

9,  area  normal  by  percussion.     No  enlargement  recognized  in  37  %. 
Group  VI.  — Weights  500  grammes  and  over.     .Sixt^v-nine  cases. 
18,  area  normal  by  percussion. 
I,  area  diminished  by  percussion.     No  enlargement  recognized  in  27  %. 

Women.     Average  Weight  in  Health  260  Grammes 

Group  I.  —  Weights  below  200  grammes.     Eight  cases. 

7.  area  normal  by  percussion.     Small  size  not  recognized  in  87  %. 
Group  II. — Weights  200-324  grammes.     Ninety-nine  cases. 

^  12.  area  enlarged  by  percussion. 
Group  III.  —  Weights  325-374  grammes.     Twenty-six  cases. 

17,  area  normal  by  percussion. 
I,  area  diminished  by  percussion.     No  enlargement  recognized  in  69  %. 

^ The  weights  of  these  12  hearts  were  as  follows:  One  weighed  23O  grammes;  two,  245; 
one,  250  ;    one,  260  ;    one,  270  ;    one,  280  ;    four,  300  ;    one,  315. 


274 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


Group  IV.  —  Weights  375-424  grammes.     Fifteen  cases. 

5,  area  normal  by  percussion. 

2.  area  diminished  by  percussion.  No  enlargement  recognized  in  46  %. 
Group   y.  —  Weights  425-474  grammes.     Twelve  cases. 

4,  area  normal  by  percussion. 

I,  area  diminished  by  percussion.  No  enlargement  recognized  in  41  %. 
Group   IV.  —  Weights  475  grammes  and  over.     Sixteen  cases. 

I,  area  normal  by  percussion. 

I,  area  diminished  by  percussion.     No  enlargement  recognized  in  12  %. 

This  comparison  between  the  zveight  of  the  heart  as  determined  at 
the  autopsy  and  the  ividtJi  of  the  heart  as  obtained  by  percussion  shows 
that :  — 

Group  I.  —  Men.  In  9  men  with  hearts  weighing  below  225  grammes 
(average  weight  of  normal  heart  290  grammes),  the  diminished  size  was 
not  recognized  by  percussion  in  88  per  cent  of  the  cases.  The  number 
of  cases  in  this  group  is  small,  but  in  the  corresponding  Group  I  of  the 
women  the  results  are  similar ;  some  hearts,  of  course,  in  both  these 
groups  may  have  been  dilated  during  life. 

Group  II.  —  In  168  men  with  hearts  varying  in  weight  from  225  to 
349  grammes,  a  variation  which  I  have  allowed  as  normal  either  side  of 
the  290  grammes,  1 1  were  diminished  in  size  by  percussion.  The  weights 
of  these  1 1  were  as  follows  :  — 

I  weighed  250  grammes  i  weighed  320  grammes 

1  "  280       "  I        "  325        " 

2  "  290       "  I        "  330        " 

1  "  300       "  I        "  340       " 

2  "  310       " 

Group  III.  —  In  74  men  with  hearts  weighing  from  350  to  399 
grammes  (average  weight  of  normal  heart  290  grammes)  no  enlargement 
was  recognized  by  percussion  in  83  per  cent  of  the  cases,  and  6,  indeed, 
were  even  recorded  as  smaller  by  this  means  of  examination. 

Group  IV.  —  In  26  men  with  hearts  weighing  from  400  to  449 
grammes  (average  weight  of  normal  heart  290  grammes)  no  enlargement 
was  recognized  by  percussion  in  61  per  cent  of  the  cases,  and,  as  in  the 
previous  group,  i  was  diminished. 

Group  V.  —  In  24  men  with  hearts  weighing  from  450  to  499  grammes 
(average  weight  of  normal  heart  290  grammes)  no  enlargement  was 
recognized  in  37  per  cent  of  the  cases. 


THE   SIZE   OF   THE    HEART 


275 


Group  VI.  —  In  69  men  with  hearts  weighing  500  grammes  and 
over  (average  weight  of  normal  heart  290  grammes),  no  enlargement  was 
recognized  by  percussion  in  27  per  cent  of  the  cases,  and  one  was 
recorded  as  diminished  in  size  by  this  method. 

It  is  not  necessary  to  go  over  the  table  for  women  in  detail,  as  it  is 
of  similar  import. 

In  this  comparison  I  have  given  the  clinical  record  the  benefit  of  the 
exclusion  of  all  cases  of  emphysema  and  stoutness. 

It  is  worthy  of  notice  that  both  these  tables  show  that  when  the 
heart  is  about  normal  the  error  made  by  percussion  is  least  frequent ; 
when  smaller  than  normal,  very  frequent ;  when  somewhat  enlarged, 
nearly  as  frequent ;  as  the  heart  grows  larger  and  larger,  the  frequency 
of  the  error  made  by  percussion  decreases,  but  the  amount  of  error  in 
a  given  case  becomes  greater. 

Let  us  now  return  to  Group  IV  for  a  moment.  In  this  group  of  26 
men,  with  hearts  weighing  from  400  to  449  grammes,  no  enlargement  was 
found  by  percussion  in  16  of  the  cases;  in  only  2  of  these  were  there 
murmurs;  in  the  remaining  10,  which  were  recognized  as  enlarged  by 
percussion,  4  had  murmurs. 

In  Group  V,  24  men,  with  hearts  weighing  from  450  to  499  grammes, 
9  hearts  were  given  as  normal  by  percussion ;  in  only  2  of  these  were 
there  murmurs;  in  the  remaining  15,  which  were  recognized  as  enlarged 
by  percussion,  8  had  murmurs.  This  may  mean  that  when  murmurs 
are  found  closer  attention  is  given  to  the  size  of  the  heart. 

It  is  evident  from  the  comparison  we  have  made  between  the  size  of 
the  heart  as  obtained  by  an  autopsy  and  by  percussion  that  the  latter 
method  is  inaccurate ;  but  the  cases  are  too  few  to  determine  the 
amount  of  the  inaccuracy. 

Comparison  of  Percussion  with  X-Ray  Examinations  in  determining 
Width  of  Heart.  —  Now  let  us  see  how  percussion  stands  as  to  accu- 
racy when  compared  with  an  X-ray  examination,  a  method  which,  like  per- 
cussion, is  used  during  life.  It  is  unnecessary  to  compare  the  two 
methods  of  determining  the  outlines  of  the  heart  so  far  as  complete- 
ness goes  ;  the  X-ray  examination  gives  much  fuller  outlines. 

First,  let  us  examine  the  table  marked  B,  which  gives  the  result  of 
this  comparison  in  155  cases  of  various  diseases.  The  left  border  in  these 
cases  was  determined  by  its  distance  from  the  median  line  in  both 
methods  of  examination.  I  have  taken  the  left  border  in  comparing  the 
two  methods  because  it  is  the  one  more  easily  determined  by  percussion. 


276 


THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


The  figures  give  the  difference  in  the  distance  of  the  left  side  of  the 
heart  from  the  median  line  as  determined  by  percussion  and  X-ray  ex- 
amination in  each  patient.  The  comparison  shows  that  percussion  is  in 
error  in  a  certain  proportion  of  cases  (how  large  a  proportion  it  is  yet 
too  early  to  estimate),  and  unfortunately  we  cannot  in  practice  determine 
without  using  the  X-rays  in  which  cases  percussion  is  wrong.  The  plus 
mark  means  that  percussion  made  the  heart  larger  than  did  the  X-ray 
examination,  and  the  minus  mark  that  percussion  made  the  heart  smaller. 

The  table  consists  of  four  double  columns ;  in  the  first  column 
the  difference  between  the  left  border  as  determined  by  percussion 
and  X-ray  examination  was  less  than  i  centimetre.  This  we  will  call 
agreement. 

In  the  second  column  the  difference  was  i  centimetre  or  more,  and 
less  than  2. 

In  the  third  column  the  difference  was  2  centimetres  and  less  than  3. 

In  the  fourth  column  the  difference  was  3  centimetres  or  more.  The 
table  also  shows  that  the  disagreement  between  the  two  methods  was 
about  as  often  plus  as  minus  in  the  155  cases. 

In  the  cases  in  the  left-hand  side  of  each  double  column  the  total 
width  of  the  heart  by  an  X-ray  examination  was  less  than  1 3  centimetres ; 
in  those  in  the  right-hand  side  it  was  13  centimetres  or  more. 

This  table  shows  the  discrepancy  between  the  position  of  the  left 
border  from  the  median  Hne  as  obtained  by  X-ray  examination  and  per- 
cussion, but  the  cases  (155)  are  too  few  in  number  by  which  to  measure 
the  exact  amount  of  discrepancy  that  would  obtain  as  a  rule  between 
these  two  methods. 


^.  — DIFFERENCE  OF  X-RAY  AND  PERCUSSION  DETERMINATIONS 
OF  LEFT  HEART  BORDER  ON  LEVEL  WITH  NIPPLE,  DURING 
EXPIRATION   IN    155   CASES.  1     (81    MEN.  44  WOMEN,  30  CHILDREN) 


Men 


Less  than  i  cm. 


Bronchitis. 


Aneurism. 
-1-1.75  -1-75 

Bronchitis. 
+  1.50 


2-3  cm. 

Aneurism. 

+  2.50 

Bronchitis. 

-t-2.00 


3  cm.  and  over. 


1  +  means  percussion  made  the  heart  larger  than  the  X-ray  examination.  —  means  percussion 
made  the  heart  smaller  than  the  X-ray  examination. 

The  left-hand  column  in  each  of  the  four  double  columns  contains  the  cases  in  which  the  heart's 
width  was  less  than  13  centimetres ;  the  right  side  those  in  which  it  was  13  centimetres  and  over. 


THE   SIZE    OF   THE    HEART 


277 


M  EN  (  Con  till  I  ted) 


Less  than  i  cm. 


Arterio-sclerosis. 


Cardiac. 


Rheumatism. 

Pleurisy. 
) 

Tuberculosis. 
) 
) 
) 
) 

Meningitis. 
Pneumonia. 

Typhoid  Fever. 

Emphysema. 
Malaria. 


Nephritis. 
+ 1. 00 


Card 

ac. 

+  1 

25 

+  1 

50 

+  1 

50 

—  I 

00 

+  1 

00 

—  I 

50 

—  I 

00 

+  1 

00 

Rheumatism. 
+  1.50  +1.40 

Pleurisy. 
-1.50 

Tuberculosis. 
-1.50 
-1.50 
-1.25 
+ 1. 00 


Pneumonia. 
1.25  -fi.25 

1.50 


Typhoid  Fever. 

+  I. GO 
—  I. GO 

Emphysema. 

+  1.75 


Malaria. 


1.50 


2-3  cm. 


Cardiac. 


+  2.GG 
+  2.00 
+  2.00 

—  2. GO 

—  2. 50 
2.2  C 


Rheumatism. 
2.25 


Tuberculosis. 

+  2.00  +2.50 

+  2.50  +2. GO 


Pneumonia. 

■2.50  +2.00 


Emphysema. 

2.00 


3  cm.  and  over. 


New  Growth. 


3  25 


Cardiac. 


-  3-00 
+  3.00 


Pleurisy. 
3. GO 

Tuberculosis. 
3-25 


Pericardial  Ad- 
hesions. 
-4.00 


278     THE    ROENTGEN    RAYS   IN    MEDICINE    AND 

Women 


SURGERY 


Less  than  i  cm. 
Bronchitis. 


Anaemia. 


Rheumatism. 


Pieiirisv. 


.0 


Tuberculosis. 
.0  .0 

.0  .0 

.0 

DebiHtv. 


Tape  Worm. 


Pneumonia. 


Cardiac. 

+  1.60  -1.50 

+  1-75  -1-75 


2-3  cm. 

3  cm.  and  over 

Aneurism. 

+  3.00 

Cardiac. 

2.50             +2.00 

-2.00 

-2.00 

Anaemia. 

2.50 

Rheumatism.         ^  Rheumatism. 

+  1. 00  —  1.50    ]    +2.00 

+  1.50 


Pieurisv. 


Tuberculosis. 
-1.50 
+  1.50 
-1.50 


Emphysema. 
-1-75 


Pleurisy. 
-  2.00 

Tuberculosis. 
-2.50 
+  2.00 


Arterio-sclerosis. 
+  2.00 

Malaria. 

+  2.00 


Pneumonia. 


Pieurisv. 


-3.00 


Tuberculosis. 
+  3-5° 


No  Aneurism. 

+  3.00 

Hysteria. 
+  3.00' 


Cardiac. 


Anaemia. 


Children 


Cardiac. 
+  1.50  -1. 00 

-1.25  +1.50 


Synovitis. 
-1.50 


Cardiac. 


-i-2.00 


Rheumatism. 


3.00 


THE   SIZE   OF   THE    HEART 


279 


Children  (^Continued) 


Less  than  i  cm. 
Tuberculosis. 


Pneumonia. 


Typhoid  Fever. 


Total  62 


Tuberculosis. 
1.25 


Typhoid  Fever. 

+  I.'25 
+  I. GO 
+  1.25 
+  1.50 

Spinal  Meningitis. 
+  1.25 

Total  49 


2-3  cm. 


Pneumonia. 
—  2.00  —2.00 


Total  31 


3  cm.  and  over. 

Tuberculosis. 
+  3.00 


Total  13 


It  should  be  stated  that  I  have  taken  pains,  from  time  to  time,  to  get 
other  physicians  to  determine  by  percussion  the  size  of  the  heart  in  some 
cases,  and  I  then  compared  it  with  that  obtained  by  an  X-ray  examina- 
tion ;  as  yet  I  have  found  no  one  whose  percussion,  Hke  mine  in  the 
same  cases,  did  not  give  the  size  of  the  heart  incorrectly  when  tested  by 
an  X-ray  examination. 

If  we  consider  the  table  {B)  in  a  general  way,  and  look  at  the  groups 
of  diseases,  it  seems  that  percussion  is  very  likely  to  err  in  finding  the 
position  of  the  left  border  of  the  heart  when  it  is  of  the  most  importance 
to  have  accurate  information  about  this  organ,  namely,  in  cardiac  disease 
when  the  heart  is  enlarged.  Percussion  also  errs  when  the  heart  is  dis- 
placed, and  the  error  under  these  conditions  is,  I  think,  more  frequent 
and  on  the  average  greater  than  when  the  heart  is  enlarged. 

The  following  cases,  and  cases  given  on  pages  285  and  286,  illustrate 
this  point :  — 

Mary  F.  D.  Entered  my  service  at  the  Boston  City  Hospital 
May  7,  1898.  The  right  chest  contained  fluid  which  pushed  the  heart 
to  the  left ;  this  displacement  was  recognized  by  the  X-rays,  but  not  by 
percussion.  It  may  be  that  displacements  are  sometimes  not  readily 
recognized  by  percussion  because  the  heart  is  pushed  into  the  body  of 
the  lung  rather  than  along  or  near  the  chest  wall.     (See  Fig.  162.) 


28o    THE    ROENTGEN    RAYS   IN    MEDICINE    AND   SURGERY 

Harry  M.  Fig.  163.  Entered  my  service  at  the  Boston  City  Hospital 
January  28,  1899.  This  case  was  an  unusual  one.  There  was  fluid  in 
the  left  chest  which  displaced  the  heart  to  the  right,  but  as  the  patient 
had  also  at  the  same  time  pneumonia  in  the  lower  part  of  the  right 
lung,  the  heart  was  not  pushed  directly  to  the  right,  but  was  forced 
upward.  Hence  the  right  border  of  the  heart  was  found  to  the  right 
and  above  a  line  joining  the  sternal  notch  and  the  right  nipple. 


Fig.    162.      Mary   F.   D.     May  7,    1898.     X-ray   tracing.     Full    line   shows   the   left   border   of   the 
heart;  broken  line  shows  this  border  as  determined  by  percussion.     (Cut  one-third  life  size.) 


The  following  cases  show  how  the  left  border  of  the  heart,  when 
obtained  by  percussion,  may  differ  from  that  seen  by  X-ray  examina- 
tion. In  the  first  case  the  percussion  line  was  inside,  in  the  second 
case  outside,  of  the  X-ray  line. 

John  W.  M.  Fig.  164.  Entered  my  service  at  the  Boston  City  Hospi- 
tal December  2,  1898.  The  X-ray  line  of  the  left  border  of  the  heart 
was  outside  of  the  percussion  line. 

Catherine  P.  Entered  my  service  at  the  Boston  City  Hospital 
December  23,  1898.  The  position  of  the  left  border  of  the  heart  as 
determined  by  the  X-ray  examination  was  inside  of  the  line  indicated  by 
percussion  (Fig.  165). 


THE   SIZE    OF   THE    HEART 


28r 


In  the  few  cases  in  which  I  have  had  an  opportunity  to  compare 
the  size  and  position  of  the  heart,  as  shown  by  an  X-ray  examination, 
with  that  found  at  autopsies,  they  have  all  agreed  ;  except  that  after 
death  the  heart,  as  already  stated,  was  somewhat  higher  than  in  life. 

When  the  heart  is  normal  in  size,  its  border,  so  far  as  it  can  be 
obtained  by  percussion,  can  usually  be  obtained  correctly  if  the  patient 


■T>.o\  tVv. 


\^o.NtN^^^    ^iNi  2.7 '99. 


iWO.TJlk. 


Fig.  163.  Harry  M.  February  27,  1899.  X-ray  tracing.  Full  line  shows  the  position  of  the  right 
border  of  the  heart;  broken  line  shows  its  position  as  determined  by  percussion.  (Cut  one- 
third  life  size.) 


is  not  too  stout  and  no  pulmonary  emphysema  is  present ;  when  it  is  of 
abnormal  size,  whether  smaller  or  greater,  this  condition  may  not  be 
exactly  indicated  by  percussion,  and  an  abnormal  size  of  the  heart  may 
be  overlooked. 

In  some  cases  the  X-rays  show,  for  example,  that  by  percussion  the 
upper  portion  of  the  left  border  of  the  heart  appears  to  be  nearer  the 


282     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY  * 

sternum  than  is  the  case.  They  also  show  in  some  cases  of  a  heart 
enlarged  on  the  left  side  that,  when  this  organ  approaches  nearer  the 
side  of  the  thorax  than  in  health,  percussion  may  give  dulness  closer 
to  the  axillary  line  than  normal,  because  there  is  too  little  lung  tissue 
between  the  left  side  of  the  thorax  and  the  heart  to  give  the  usual 
resonance  to  percussion,  and  therefore  the  width  of  the  left  heart  would 
be  overestimated  by  percussion. 


Fig.  164.     John  W.  M.     December  17,  1899.    X-ray  tracing.     Full  line  shows  position  of  left  border 
of  heart ;  broken  line,  its  position  as  determined  by  percussion.     (Cut  one-third  lite  size.) 


The  right  border  of  the  heart  is  often  difficult  to  place  by  percus- 
sion, because  it  lies  away  from  the  chest  wall.  The  thickness  of  this 
wall  is  another  important  factor  to  be  taken  into  account  when  consid- 
ering the  accuracy  of  percussion.  That  is,  varying  distances  of  the 
border  of  the  heart  from  the  chest  wall  and  variations  in  the  thickness 
of  this  wall  would  affect  the  results  obtained  by  percussion. 

In  a  word,  percussion  as  a  rule  indicates  what  Hes  near  the  inner 
side  of  the  chest  wall  (but  not  much  beyond,  as  is  shown  by  the  failure 
to  determine  the  cardiac  border  in  pulmonary  emphysema);  but  when 


DISPLACED    HEART  283 

a  heart  is  much  enlarged  to  the  left  it  may  lead  the  practitioner  to  a  wrong 
interpretation  of  the  conditions  present. 

Small  hearts  may  be  recognized  by  an  X-ray  examination,  and  also 
the  presence  of  an  abnormal  condition  in  congenital  malformations. 
The  ability  to  recognize  with  certainty  that  the  heart  is  smaller  than 
normal  may  be  of  much  service  to  the  patient  both  in  treatment  and 
prognosis. 


Fig.  165.    Catherine  P.     January  2,  1899.    X-ray  tracing.     Full  line  shows  position  of  left  border 
of  heart;  broken  line,  its  position  as  determined  by  percussion.     (Cut  one-third  life  size.) 

If  by  an  X-ray  examination  we  iind  in  any  patient  (excluding  acute 
diseases)  an  enlarged  heart,  we  should  consider  among  the  probable 
causes  the  presence  of  valvular  lesions,  arterio-sclerosis  (especially  in 
middle  age  and  after),  renal  disease,  and  emphysema  of  the  lungs;  this 
last  condition  would  be  very  obvious  by  an  X-ray  examination. 

SECTION    IV 

DISPLACED  HEART 

We  will  now  further  examine  the  heart  when  the  normal  outlines 
described  in  the  first  section  have  been  modified  by  conditions  existing 
outside  of  this  organ.     Various  causes  acting  from  without  may  change 


284     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

the  position  of  the  heart,  and  this  variation  in  position  from  the  normal 
may  suggest  to  the  physician  the  diseased  condition  that  has  produced 
this  change. 

Displacement  of  the  Heart. — The  heart  is  suspended   from  above, 
and  is  surrounded  by  the  pericardium,  which  is  attached  to  the  blood 


Fig.  166.     Alex.  M.     Cut  shows  the  difference  in  the  position  of  the  left  border  of  the  heart  as  deter- 
mined by  the  X-rays  and  by  percussion  both  before  and  after  operation.     (Cut  one-third  life  size.) 

vessels  above  and  to  the  diaphragm  below ;  and  its  position  may  be 
much  changed.  It  appears  possible  to  find  it  either  pushed  or  pulled 
into  almost  any  portion  of  the  thoracic  cavity.  It  may  be  found  so  low 
in  the  chest  that  its  pulsations  are  felt  under  the  ensiform  cartilage  ;  it 
may  be  so  pushed  to  the  left  that  the  apex  is  much  outside  the  nipple 
line ;  or  upward  and  to  the  right,  so  that  the  right  border  is  above  the 


DISPLACED    HEART  285 

line  extending  from  the  right  nipple  to  the  inner  end  of  the  clavicle 
(see  Fig.  163,  Harry  M.,  Section  III,  page  281)  ;  or  it  may  be  pushed 
still  farther  upward  to  the  very  top  of  the  thoracic  cavity.  Figure  168 
(P.  S. )  shows  the  diaphragm  pushed  high  up  in  the  chest.  The  pulsations 
of  the  heart  could  be  made  out  above  this  point. 

Causes  of  Displacement 

(a)  Fluid  or  gas  in  pleural  cavities.  — The  heart  may  be  moved  to 
one  side  or  the  other  by  a  large  amount  of  fluid  or  gas  in  the  pleural 
cavity,  more  especially  in  the  pleura  on  the  left  side.  The  following 
cases  are  illustrative  :  — 

Case  I.  Alex.  M.  Entered  my  service  at  the  Boston  City  Hospi- 
tal April  28,  1898.  He  had  a  very  large  pleuritic  effusion  in  the  right 
side,  which  pushed  the  heart  far  to  the  left  and  much  outside  the  left 
nipple. 


oi 


NxcarV    nwbVvtdVo  vv^WV,. 

Fig.  167.    Constantin  D.     Cut  shows  the  difference  between  the  right  border  of  the  heart  as  deter 
mined  by  the  X-rays  and  by  percussion. 

X-Ray  Examination  zvith  Screen. — The  position  of  the  left  border 
of  the  heart  before  the  fluid  was  withdrawn  is  shown  by  the  full  line 
(see  Fig.  166) ;  after  its  withdrawal  by  the  dotted  line  crossing  the  nipple. 
The  position  of  the  same  border  as  determined  by  percussion  before  the 
operation  is  shown  by  the  broken  line  ;  after  operation  by  the  dotted 
line  inside  of  it. 


286     THE    ROENTGEN   RAYS   IN    MEDICINE   AND   SURGERY 

Case  II.  Constantin  D.  Entered  my  service  at  the  Boston  City 
Hospital  January  20,    1899. 

X-Ray  Exainitiatioii  ivith  Sorcn.  —  The  right  border  of  the  heart, 
which  is  indicated  by  the  full  line  (see  Fig.  167),  was  pushed  toward  the 
right  nipple  by  fluid  in  the  left  chest.  The  broken  line  indicates  this 
border  as  determined  by  percussion.  There  was  an  error  of  4.7 
centimetres  by  the  latter  method.     (See  also  cases  in  Section  III.) 

(/;)  Changes  in  Position  and  Excursion  of  Diaphragm.  —  The  position 
of  the  heart  and  the  inclination  of  its  long  axis  seems  frequently  to  de- 
pend upon  the  position  of  the  diaphragm.  If  the  muscle  is  rather 
higher  than  normal,  the  long  axis  of  the  heart  becomes  more  inclined 
toward  the  horizontal,  and  if  lower  than  normal,  the  long  axis  approaches 
the  vertical.  The  heart  may  be  pushed  up  by  the  diaphragm  when  this 
muscle  is  forced  upward  by  gas  or  fluid  in  the  abdominal  cavity,  and  its 
axis  may  thus  be  made  more  horizontal.  By  percussion  this  change  in 
position  may  be  mistaken  for  an  enlargement  of  the  heart  to  the  left, 
but  it  would  be  rightly  interpreted  by  the  X-rays. 

Case  I.  Displacement  of  Heart  by  Diaphragm  and  Distended  Abdo- 
men.—  P.  S.,  forty-four  years  of  age,  entered  the  Boston  City  Hospital 
July  I  ;  in  Dr.  Abner  Post's  service. 

History.  — •  During  past  twenty-one  years  had  had  attacks  which 
were  called  angina  pectoris.  In  1885  had  an  attack  of  abdominal  pain; 
another  in  1894,  similar  to  the  present  one,  but  less  severe. 

Present  Illness.  — June  29,  1899,  cramplike  pains  in  the  belly,  later 
localized  in  the  lower  right  abdomen ;  in  evening  began  to  vomit ; 
bowels  moved  once  on  the  29th  and  three  times  on  the  30th,  but  not  on 
July  I.  At  entrance  the  abdomen  was  distended,  rigid,  tender,  and 
tympanitic ;  tenderness  in  the  region  of  the  appendix ;  pain  in  the 
upper  left  chest.  The  heart's  border,  by  percussion,  was  2.5  centimetres 
to  the  right  of  the  sternum  ;  apex  1.25  centimetres  inside  of  nipple  line; 
dulness  on  the  right  of  the  sternum  extended  to  the  clavicle  ;  heart's 
sounds  appeared  normal.  At  7  p.m.  the  patient  was  sitting  up,  with 
intense  pain  in  the  cardiac  region  ;  abdomen  rigid  ;  respiration  rapid 
and  painful. 

July  2.  Patient  fairly  comfortable ;  less  pain  around  the  heart ; 
respiration  still  increased ;  stomach  did  not  retain  milk ;  movement  of 
bowels  after  enema. 

July  $.  Patient  steadily  improving ;  bowels  moved  by  enema  with- 
out disturbance. 


DISPLACED    HEART 


287 


July  7.  My  X-ray  examination  showed  a  marked  displacement  up- 
ward of  the  heart.  The  diaphragm  is  also  pushed  high  up  in  the  chest, 
above  the  nipples  ;  excursion  1.9  centimetres  on  the  left  side;  2.5  centi- 
metres on  the  right  side.  Abdominal  symptoms  have  improved,  but 
patient  complains  of  pain  in  the  lower  right  chest.  (See  Fig.  168,  Paul 
S.,  first  examination  July  7.) 


Paaf  J 
Hecir/'  Pa^hefl  Up 
1st  Exam    jJ^  7^^ 


Fig.  168.     Paul  S.    July  7.     Cut  of  tracing  from  first  X-ray  examination.     (Cut  one-third  life  size.) 

Heart  pushed  up. 


Paa/6 
20^ Fxa/n  i/£//y/4^ 


0-45^. 


Fig.  169.    Paul  S.    July  14.    Cut  of  tracing  from  second  X-ray  examination.    (Cut  one-third  life  size.) 
Position  of  heart  nearer  the  normal. 


288     THE    ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 

////)'  12.  Patient  up  in  a  chair  in  blankets.  July  9  and  14,  respec- 
tively, had  an  enormous  movement  from  the  bowels.    Clothes  on  July  14. 

Jiilv  14.  Second  X-ray  cxai/iination  showed  that  the  heart  was  in 
a  more  nearly  normal  position,  and  the  excursion  of  the  diaphragm  was 
lower  in  the  thorax.     (See  Fig.  169,  second  examination  July  14th.) 

Discharged  from  the  hospital  July  15. 

From  this  patient  it  will  be  readily  seen  how  seriously  the  heart  may 
be  handicapped  by  excessive  abdominal  distension,  and  in  a  disease  like 
typhoid  fever  we  should  exercise  extreme  caution  about  the  amount  and 
character  of  the  food,  in  order  to  prevent  distension  ;  and  if  it  is  present, 
we  should  reduce  it  by  suitable  means,  and  not  allow  it  to  progress  so 
far  as  to  seriously  handicap  the  patient  through  upward  pressure  of 
the  diaphragm  and  consequent  crowding  of  the  lungs  and  heart. 

The  heart  may  be  drawn  downward  by  the  diaphragm,  normally  when 
the  muscle  goes  low  down  in  the  chest  in  deep  inspiration,  and  abnor- 
mally when  the  diaphragm  is  pushed  down  in  emphysema. 

Unequal  Excursion  of  the  Two  Sides  of  the  Diaphragm.  —  The  effect  on 
the  heart  of  unequal  excursions  of  the  diaphragm  should  be  noted. 
When  the  movement  of  the  diaphragm  is  much  greater  on  the  left  side 
than  on  the  right,  the  change  in  the  position  of  the  heart  during  deep 
inspiration  may  be  greater  toward  the  right  than  it  would  be  if  both  sides 
of  the  diaphragm  descended  normally.  An  unusual  lateral  movement 
■of  the  heart  may  be  due  to  the  fact  that  the  excursion  on  one  side  is 
greater  than  on  the  other. 

(r)  Tuberculosis  and  Unequal  Excursion  of  Diaphragm.  —  In  early 
tuberculosis  of  one  side,  the  heart,  at  full  inspiration,  may  be  drawn  or 
pushed,  or  both  drawn  and  pushed,  toward  the  affected  side.  This 
•change  in  the  position  of  the  heart  may  be  due  to  the  contraction  of  the 
lung,  the  result  of  which  would  be  to  draw  the  heart  toward  the  former 
organ  ;  or  it  may  result  from  the  greater  excursion  of  the  diaphragm  on 
one  side  than  the  other  ;  for  if  there  is  a  marked  difference  in  the  move- 
ment of  the  diaphragm  in  the  two  sides  of  the  chest,  the  effect  would 
be  to  push  the  heart  farther  over  toward  the  diseased  side  than  it  would 
naturally  go  did  both  sides  of  the  diaphragm  move  normally.  Later  in 
the  disease  the  right  side  of  the  heart  may  be  enlarged,  owing  to  the 
obstruction  of  the  circulation  in  the  lung. 

{d)  Pneumonia  and  Unequal  Excursion  of  Diaphragm.  —  Displace- 
ment may  be  caused  by  a  solid  pneumonic  left  lung.      I  do  not  think 


DISPLACED    HEART 


289 


that  the  position  of  the  right  border  of  the  heart  further  to  the  right 
than  normal,  which  occurs  in  left-sided  pneumonia,  is  wholly  due  in 
all  cases  to  enlargement  of  this  organ,  but  in  some  patients  to  a 
displacement  which   is  caused  by  the  dense  and  resistant  left  lung. 


M/che/F 
Eano  IZ/iejxafoMa 


Fig.  170.  Michel  F.  December  17,  1898.  Diagnosis  :  acute  articular  rheumatism.  X-ray 
examination  shows  that  the  apex  on  right  side  is  darkened.  Broken  and  nearly  horizontal 
lines  on  either  side  show  position  of  diaphragm  in  expiration ;  the  full  lines  below,  in  forced  inspira- 
tion. It  will  be  noticed  that  the  excursion  of  the  diaphragm  on  the  right  side  is  shorter  than  on  the 
left.  The  heart  during  forced  inspiration  moves  more  to  the  right  than  normal,  because  the  right  lung 
expands  less  than  the  left.     (Cut  one-third  life  size.) 


The  heart  is  not  able  to  sink  into  the  lung  tissue  as  deeply  as  usual. 
During  convalescence  from  pneumonia  on  one  side,  the  heart  may  have 
an  unusual  lateral  movement  in  deep  inspiration,  owing  to  the  unequal 
excursion  of  the  respective  sides  of  the  diaphragm. 

In  one  of  my  patients,  Mabel  L.  (Fig.  171),  the  movement  of  the  dia- 


290     THE    ROF.XTCxEN    RAYS   IN    MEDICINE    AND    SURGERY 

phragm  on  the  right  side  was  1.9  centimetres  and  on  the  left  side 
5  centimetres,  and  the  distance  between  the  left  border  of  the  heart  in 
expiration  and  inspiration  was  3  centimetres.  This  point  will  be  better 
understood  by  comparing  this  tracing  with  Fig.  75  (Gertrude  S.), 
page  102,  in  which  the  heart  moves  normally. 


Mnbef  L 
fhemonk.  Excursions  of  Djof^mjm  OnPOaal 
loJiueiKc  on  cxcorsjo/h''  u/ /i'art 


Fig.  171.  Mabel  L.  Cut  of  tracing  made  with  screen  on  front  of  chest.  (Cut  one-thiid  life 
size.)  Pneumonia  ot  right  lung;  excursion  of  two  sides  ot  diaphragm  unequal.  Influence  on  move- 
ment of  heart,  which  is  drawn  to  the  right  by  the  diminished  expansion  of  the  right  lung  and  pushed 
to  the  right  by  the  relatively  greater  expansion  of  the  left  lung.  Compare  normal  outlines  shown  in 
Fig.  75,  Gertrude  S. 

{e)  Aneurisms  and  New  Growths. — The  heart  may  also  be  pushed 
out  of  place  by  aneurisms  in  the  thoracic  cavity,  or  by  new  growths  in 
this  cavity  or  the  abdomen.  The  subject  of  aneurisms  and  new  growths 
is  taken  up  in  Chapters  XI  and  XII  respectively,  therefore  need  not  be 
further  discussed  here. 

(/)  Contractions  and  Adhesions.  —  There  are  cases  in  which  the 
heart  is  drawn  out  of,  rather  than  pushed  out  of,  position.  Its  place 
may  be  changed  by  the  diminution  in  the  volume  of  one  lung,  as  in 


DISPLACED    HEART  29 1 

early  tuberculosis  ;  or  by  the  contraction  of  one  lung  and  pleura ;  or 
by  pleuritic  adhesions. 

During  full  inspiration  the  heart  is  made  to  assume  a  lower  position 
in  the  chest,  and  its  axis  becomes  more  nearly  vertical  than  in  expira- 
tion, but  it  sometimes  happens  that  though  the  excursion  of  the  dia- 
phragm is  normal,  the  heart  at  this  period  of  the  respiratory  movement 
is  tilted  in  some  peculiar  manner,  or  fails  to  move,  owing  to  the  pres- 
ence of  adhesions.  Adhesions  near  the  upper  left  border  of  the  heart 
may  so  hold  it  that  its  apex  moves  upward  and  to  the  left  during  in- 
spiration, instead  of  downward  and  to  the  right.  Or  if  adhesions  are 
present  in  the  right  lower  border,  this  organ  may  be  suddenly  jerked  to 
the  right  toward  the  end  of  inspiration. 

The  following  cases  are  illustrative  :  — 

Pleurisy  and  Pulmonary  Fibrosis  causing  Displacement  of  Heart.  — 
The  following  patient  shows  how  the  heart  may  be  drawn  to  the  right 
and  backward  when  the  right  lung  and  pleura  are  contracted  :  — 

Mary  I.,  twenty-three  years  old,  entered  the  medical  side  of  the 
Boston  City  Hospital  July  8,  1886,  service  of  the  late  Dr.  E.  J.  Forster. 
Diagnosis  :  pulmonary  tuberculosis. 

She  had  night  sweats;  pain  in  the  right  side;  temperature  104; 
respiration  32;  pulse  144;  heart  negative. 

Lungs  :  dull  throughout  the  right  chest,  especially  above  the  third 
rib  and  the  spine  of  scapula,  where  breathing  is  broncho-vesicular  with 
numerous  crackling  rales  and  increased  voice  sounds  ;  below  clavicle 
and  at  spine  of  scapula,  small  areas  of  cavernous  respiration  and  bub- 
bling rales  with  bronchophony.  In  lower  half  of  right  chest,  crackling 
rales,  but  not  so  numerous  as  above. 

In  1890  she  entered  the  surgical  side  of  the  City  Hospital,  and  Dr. 
Post  removed  a  fibro-sarcoma  from  the  right  side  of  the  neck,  behind 
the  sternocleidomastoid  muscle.  It  was  dissected  out,  and  found  by 
Dr.  Henry  Sears  to  consist  of  a  mass  of  dense  white  tissue  with  fibrous 
tissue  structure  in  places,  and  was  very  cellular.  She  was  discharged 
September  22. 

In  1898  she  returned  to  the  hospital  (March  30),  and  was  in  the  ser- 
vice of  Dr.  Bowditch.      Diagnosis  :  pulmonary  fibrosis.     Hsematuria. 

Hemorrhage  from  the  lungs  eight  years  ago.  Since  then  considera- 
ble yellowish  and  greenish  expectoration  night  and  morning. 

No  tubercle  bacilli  found  in  sputum  in  four  examinations.  The  mal- 
position of  the  heart  thought  to  be  due  to  the  probable  fibrosis  of  right  lung. 


292 


THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


May  2S.  Examination  ivitJi  Screen  (see  Fig.  172).  —  I  found  the 
heart  was  chiefly  on  the  right  side  of  the  sternum.  The  whole  right 
side  was  dark,  and  no  outhnes  whatsoever  could  be  followed  there. 
When  the  patient  lay  on  her  back  there  was  seen  a  nearly  vertical, 
somewhat  curved,  line  about  3.7  centimetres  to  the  left  of  the  sternum. 
As  the  patient  turned  to  the  left,  this  outline  moved  toward  the  right 


Marcf  I 
J-learl'  Dreiwn  lb  HMbtoncf Backwaid^ 


Fig,  172.  Mary  I.  Cut  of  tracing  made  with  screen  on  fiont  of  chest.  (Cut  one-third  life 
size.)  Pulmonary  hbrosis.  Heart  drawn  to  the  right  and  backward.  The  full  line  indicates  limit  of 
dark  area  with  patient  lying  flat  on  her  back.  When  she  turned  to  the  left,  the  limit  of  the  dark  area 
moved  to  the  broken  line  marked  i ;  by  turning  still  more,  to  the  broken  line  marked  2 ;  and  by 
further  turning,  the  outline  was  as  shown  at  3,  thus  showing  that  the  heart  was  drawn  away  from 
the  sternum.  In  other  words,  when  she  had  turned  sufficiently,  the  whole  of  the  thorax  to  her  left  of 
line  3  was  clear  and  to  her  right  of  it  was  dark. 


nipple,  and  as  she  turned  more  and  more,  came  nearly  to  it,  and  assumed 
a  curve  resembling  somewhat  the  left  border  of  the  heart.  (See  i,  2, 
and  3  in  cut.)  These  appearances  would  indicate  that  the  heart  had 
not  only  been  drawn  to  the  right,  but  had  also  been  drawn  back  from 
the  anterior  wall  of  the  chest. 


DISPLACED    HEART 


293 


This  patient  had  had  pulmonary  fibrosis,  and  the  heart  has  probably 
been  drawn  to  the  right  by  the  contraction  of  the  lung  and  pleura. 

May  31.     Discharged  relieved. 

Displacement  of  Heart  by  Pericardial  or  Pleuritic  Adhesions.  — 
D.  F.  W.,  forty-two  years  old;  entered  the  hospital  December,  1898. 
Service  of  Dr.  G.  B.  Shattuck.  Diagnosis  :  emphysema  and  displaced 
heart. 


heart  DrauJn  lb  Rjji 
6u  Jdhesions 


@ 


Fig.  173.  D.  F.  W.  X-ray  tracing  (one-third  life  size).  Heart  drawn  to  the  right.  Full  lines 
indicate  the  position  of  heart  and  diaphragm  in  full  inspiration  ;  broken  lines  in  expiration.  This 
movement  is  exceptional,  as  usually  the  right  side  of  the  heart  in  full  inspiration  would  not  move 
in  this  way. 

The  question  of  an  aneurism  or  a  new  growth  in  the  chest  was  also 
considered. 

X-Rav  Examination  xvith  Screen. — I  found  the  heart  was  farther 
to  the  right  than  normal  during  quiet  breathing,  and  was  drawn  about 
I  centimetre  farther  still  to  the  right  during  deep  inspiration.  In  the 
angle  made  by  the  right  border  of  the  heart  and  the  upper  border  of  the 
diaphragm,  a  darkened  area  was  seen  during  full  inspiration.  This 
examination  showed  conclusively  that  there  was  no  aneurism. 

My  interpretation  of  the  appearances  seen  on  the  screen  was  as  fol- 


294 


THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURCiERV 


lows :  The  heart  was  drawn  to  the  right  by  adhesions,  and  the  darkened 
area  on  the  right  side  of  the  heart  was  perhaps  the  shadow  of  thickened 
tissue,  by  means  of  which  this  organ  was   pulled   out  of  its  normal 


P/ieumonjo     Exciir^jorj ./  fieurt 


Fig.  174.  Edward  W.  April,  1897.  Convalescent  from  pneumonia  on  left  side.  Slight  signs 
of  tuberculosis  at  right  side.  Full  lines  show  outline  of  heart  and  diaphragm  in  deep  inspiration ; 
broken  lines  in  expiration.  Heart  is  drawn  to  the  left  in  full  inspiration,  instead  of  to  the  right,  as 
usual.  In  the  beginning  of  expiration  the  diaphragm  moves  up  on  the  left  side  first  (i),  then  on  the 
right  side  (2),  and  reaches  the  position  of  expiration  on  the  left  side  at  (3),  before  the  diaphragm 
arrives  on  the  right  side  at  (4).;  the  order  being  i,  2,3,4.  The  heart  tips  back  into  the  position 
of  expiration  (broken  line)  as  soon  as  the  left  diaphragm  lifts  (at  the  beginning  of  expiration  after  a 
deep  inspiration),  and  as  though  it  were  let  go  suddenly.  The  heart  is  evidently  held  and  cannot 
descend  in  full  inspiration.  The  right  apex  should  be  shaded,  but  the  shading  is  omitted  because  it 
would  mterfere  with  the  name  and  date.     (Cut  one-third  life  size.) 


position  when  the  diaphragm  descended ;  that  is,  at  each  descent  the 
heart  was  jerked  to  the  right  towards  the  end  of  inspiration. 

Heart  attached  ;  Movements  unusual   during  Full  Inspiration.  —  Ed- 
ward \V.  (see  Fig.  174),  twenty-two  years  old,  entered  my  service  at  the 


DISPLACED    HEART 


295 


Boston  City  Hospital  April  24,  1897,  with  pneumonia  on  the  left  side.  He 
had  a  chill  one  week  before  entrance.  Pain  in  the  left  side,  more  marked 
on  deep  inspiration ;  some  cough ;  no  expectoration ;  heart  normal. 
Lungs  :  good  resonance  and  respiration  over  right  lung  ;  some  dulness  at 
the  left  apex  in  the  back,  extending  down  5  centimetres  below  the  spine 
of  scapula  ;  breathing  at  apex  prolonged,  with  a  few  fine,  moist,  and  occa- 
sional crackling  rales  after  cough  ;  breathing  in  the  middle  of  the  left 
back  was  broncho-vesicular  in  character,  and  harsher  than  in  right  back ; 
vocal  and  tactile  fremitus  slightly  increased. 

April  29.  X-Ray  Exaniinatioii.  —  Darkened  area  extending  out- 
ward and  upward  from  the  heart  on  the  left  side ;  shortened  excursion 
of  diaphragm  on  this  side.  This  indicated  an  unresolved  pneumonia. 
Over  this  dark  pulmonic  area  rales  and  a  pleuritic  rub  were  heard,  and 
the  patient  reported  that  for  the  past  year  and  a  half,  when  he  coughed, 
it  "caught"  him  there.  Right  apex  somewhat  darker  than  normal; 
excursion  of  diaphragm  on  right  side  higher  and  shorter  than  normal. 
These  conditions  suggested  tuberculosis  at  the  right  apex.  Tuberculin 
given  ;   reaction. 

June  2.  Second  X-Ray  Examination.  — The  right  apex  was  clearer 
than  on  April  29 ;  excursion  of  the  diaphragm  on  this  side  had  increased, 
but  it  was  still  higher  in  position  than  normal.  On  the  left  side  the 
darkened  area  was  less  marked,  and  the  excursion  of  the  diaphragm  6.25 
centimetres.  The  heart  moved  much  less  than  in  health  during  deep 
inspiration,  the  left  border  moved  outward  and  upward  instead  of  down- 
ward and  toward  the  median  line,  and  the  right  border  moved  inward  and 
toward  the  median  line.  The  heart  was  evidently  held,  and  did  not 
descend  during  full  inspiration,  as  usual,  with  the  diaphragm  ;  therefore 
its  lower  border  was  seen  more  completely  than  is  possible  in  health. 

Displacement  of  Heart  simulating  Enlargement  by  Percussion.  —  The 
width  of  the  heart,  as  determined  by  percussion,  is  the  horizontal  dis- 
tance between  the  right  and  left  borders.  X-ray  examinations  show  that 
the  axis  of  the  heart  in  some  patients  is  more  inclined  than  in  others, 
and  therefore  a  width  of  this  organ  taken  in  a  horizontal  line  might  give 
too  great  measurement.  A  heart  whose  position  has  been  changed  may 
sometimes  be  mistaken  for  an  enlarged  heart.  For  example,  when  the 
diaphragm  is  a  little  higher  than  normal,  the  axis  of  the  heart  may  also 
be  more  horizontal ;  as  a  result  of  this  direction  of  the  axis  the  left  bor- 
der of  the  heart  is  turned  more  toward  the  left,  and  this  organ  seems 
enlarged  on  the  left  side.     This  displacement  of  the  heart  may  be  mis- 


296     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

interpreted  by  percussion,  and  a  diagnosis  of  enlargement  made  where 
none  exists.  The  following  case  illustrates  the  advantage  of  an  X-ray- 
examination  when  the  heart  is  not  in  its  usual  place  :  — 

This  patient,  fifty  years  old,  was  referred  to  me,  as  it  was  thought  by 
his  physician  that  he  had  cardiac  disease.  I  found  by  percussion  that 
the  left  border  of  the  heart,  as  well  as  the  apex  beat,  was  outside  of  the 
nipple  line ;  the  right  border  was  not  clearly  defined,  but  seemed  to  be 
in  about  the  usual  place. 

The  X-ray  exaDiination  showed  that  the  diaphragm  on  the  left  side 
moved  2.5  centimetres  ;  on  the  right  side,  3.7  centimetres.  The  heart 
was  drawn  to  the  left  and  upward.  Upon  inquiry  I  learned  that  he 
had  had  pneumonia  and  pleurisy  forty-three  years  before.  I  then  told 
him  they  had  been  on  the  left  side,  to  which  he  repHed  in  the  affirma- 
tive. But  for  the  X-ray  examination  I  should  have  considered  that  the 
patient  had  an  enlarged  heart,  but  this  examination  showed  that  his  heart 
was  not  enlarged  but  simply  displaced. 

In  another  case,  in  which  by  percussion  the  left  border  of  the  heart 
and  the  apex  beat  were  outside  the  nipple  line,  the  X-ray  examination 
showed  that  the  organ  was  neither  enlarged  nor  displaced,  as  percus- 
sion and  palpation  led  the  physician  to  believe,  but  that  its  axis  was 
unusually  horizontal,  and  this  brought  the  apex  beat  farther  to  the  left 
than  if  the  axis  of  the  heart  had  had  the  usual  inclination. 

The  following  tracing  illustrates  this  point,  and  shows  that  the  axis 
of  the  heart  may  be  so  much  more  horizontal  than  in  health  that  the 
apex  beat  is  nearly  in  the  nipple  line,  and  if  percussion  gives  dulness 
in  a  fine  above  this  point,  the  physician  might  be  easily  led  to  over- 
estimate the  size  of  the  heart,  as  by  this  method  he  might  not  recog- 
nize the  inclined  position  of  its  right  border,  whereas,  as  the  tracing 
shows,  he  could  obtain  an  accurate  knowledge  of  the  size  and  position 
of  this  organ  by  an  X-ray  examination  (Fig.  175). 

In  this  patient,  the  diaphragm  was  rather  higher  than  usual  in  the 
thorax.  The  long  axis  of  the  heart  was  nearly  horizontal.  The  heart 
was  dilated.  The  outline  of  the  right  ventricle  and  right  auricle  could 
be  plainly  followed  to  the  right  of  the  sternum.  During  a  forced  deep 
inspiration,  the  heart  was  diminished  in  size  both  in  its  vertical  and 
horizontal  diameters.  This  suggested  dilatation  of  the  heart  rather 
than  hypertrophy. 

This  case  shows  that  the  axis  of  the  heart  may  be  so  nearly 
horizontal  as  to  give,  to  a  physical  examination,  the  signs  of    a  heart 


DISPLACED    HEART 


297 


which  is  very  much  enlarged  (the  heart  was  enlarged  in  this  case,  but 
its  horizontal  position  exaggerated  this  unduly),  as  will  be  readily  seen 
by  the  tracing. 

Chlorosis.  —  In  cases  of  chlorosis,  the  heart  may  seem  by  percussion 
to  be  enlarged  both  to  the  right  and  left,  and  by  a  later  examination, 
made  after  the  patient  has  improved,  to  be  more  nearly  normal  in  size  ; 
but  this  apparent  decrease  in  size,  as  determined  by  percussion,  is  shown 


John  C 


Fig.  175.  John  C.  Cut  of  tracing  made  with  screen  on  front  of  chest.  (Cut  one-third  life  size.) 
Full  lines  show  position  of  heart  during  deep  inspiration ;  broken  lines,  position  during  expiration. 
Heart's  axis  nearly  horizontal. 

by  the  fluorescent  screen  to  be  in  reality  due  to  the  descent  of  the 
diaphragm,  and  the  consequent  change  in  the  direction  of  the  long 
axis  of  the  heart ;  as  in  the  cases  given  above,  the  heart  has  been 
displaced. 

Anaemia.  —  In  anasmia  with  constipation,  the  diaphragm  would  be 
higher  than  normal,  thus  tipping  the  heart  and  making  it  appear  to 
have  greater  width.     (See  page  389.) 

Unusual  positions  of  the  heart  and  transposition  of  this  organ  are 


298     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

often  easily  recognized  by  an  X-ray  examination,  when  by  other  meth- 
ods their  recognition  would  be  uncertain  or  difihcult. 
'    A  Case  of  Apparent  Dextrocardia.     This  case  illustrates  the  advan- 
tages which  fluoroscopic  examinations  have  over  those  with  a  radiograph 
or  the  usual  physical  examination. 

A.  B.,  a  patient  of  Dr.  ,  had  been  carefully  examined  by  two 

excellent  physicians,  and  the  diagnosis  of  dextrocardia  was  made  after 
a  thorough  physical  examination.  A  radiograph  of  the  heart  was 
also  made,  which  showed  a  sharply  defined  cardiac  border  much  to  the 
right  of  the  median  line,  and  that  the  heart  extended  only  a  short  dis- 
tance to  the  left  of  the  sternum,  and  that  this  outline  was  not  at  all 
defined.  The  radiograph  was  considered  to  lend  confirmatory  evidence 
to  the  diagnosis  of  dextrocardia  made  by  the  history  and  physical 
examination. 

At  this  stage,  the  patient  was  brought  to  me  by  his  physician, 
that  I  might  make  an  examination  with  the  fluoroscope,  in  order 
that  my  outlines  might  be  used  in  the  report  of  the  case.  I  saw 
him  only  once,  but  the  examination  with  the  screen  was  sufficient  to 
demonstrate  clearly  that  his  heart  was  simply  drawn  to  the  right,  prob- 
ably as  the  result  of  a  pleurisy,  which  he  had  had  on  the  right  side  five 
years  previously.  The  right  border  was  far  to  the  right  of  the  median 
line,  and  close  to  the  front  wall  of  the  thorax  ;  the  left  border  was  a 
little  to  the  left  of  the  median  line,  but  some  distance  from  the  anterior 
chest  wall,  as  could  be  readily  determined  by  examining  the  patient 
while  sitting  up  and  looking  through  the  chest  at  an  angle.  In  this 
position  the  whole  of  the  anterior  part  of  the  left  thoracic  cavity  was 
seen  to  be  free  from  heart.  The  above  conditions  were  readily  demon- 
strated to  the  physician  of  the  patient,  who  accepted  the  diagnosis 
without  hesitation  as  complete  and  final. 

SECTION    V 

OTHER  ABNORMAL  CONDITIONS  OF  THE  HEART 

Pulsations.  —  The  pulsations  of  the  heart  may  be  followed  in  cases 
of  irregular  action,  as  in  myocarditis  ;  and  it  may  be  seen  that  they  do 
not  correspond  to  the  pulsations  at  the  wrist,  that  is,  there  are  some- 
times incomplete  pulsations  of  the  heart  which  do  not  give  an  impulse 
at  the  radial  artery. 


OTHER   ABNORMAL   COxXDITIONS   OF   THE    HEART        299 

Pulsations  of  the  Heart  in  Cardiac  Disease  shown  by  X-Ray 
Examination.  —  In  cases  of  marked  insufficiency  of  either  the  aortic 
or  mitral  valve,  or  both,  the  excursion  of  the  left  border  of  the  heart. 


Fio.  176.     John  D.     Aortic  insufficiency. 

Diagram  of  heart  in  a  patient  with  aortic  insutticiency.  Compare  with  Fig.  157,  normal 
movements.  Diastole  and  systole  during  ordiiian'  respiration  are  indicated  by  the  arrows  pointing  to 
the  broken  and  the  dotted  lines  respectively.  The  line  made  up  of  dashes  and  dots  shows  where  the  left 
border  of  the  heart  is  in  systole  during  deep  inspiration.  When  a  full  breath  is  taken  the  diastolic 
excursion  is  less  than  in  ordinary  breathing.  The  movements  of  the  heart  could  be  followed  in  this 
patient  unusually  well. 


between  systole  and  diastole,  is  much  greater  than  under  normal  con- 
ditions. Not  only  is  the  to  and  fro  excursion  greater,  but  the  length 
of  the  heart's  border  which  is  seen  to  move  is  much  longer.  (See 
Fig.  176,  John  D.) 


300     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

Slight  dilatations  of  the  aorta  may  be  seen  in  aortic  insufficiency, 
and  the  pulsations  of  this  artery  may  be  observed. 

An  X-ray  examination  also  shows  that  in  some  cases  the  movement 
of  the  heart  between  systole  and  diastole  is  much  diminished  during  a 
deep  forced  inspiration.  This  diminished  movement  may  be  caused  by 
a  lessened  regurgitation  of  the  blood,  or  it  may  show  that  the  heart  is 
dilated  rather  than  hypertrophied.  I  have  found  by  means  of  the 
X-rays  that  some  hearts,  which  by  the  ordinary  methods  of  examination 
I  considered  to  be  dilated,  were  smaller  in  size  during  forced  inspiration 
than  during  quiet  breathing. 

Pericardial  Effusion.  — When  the  cardiac  area  is  enlarged,  we  should 
note  carefully  whether  or  not  the  pulsations  of  the  left  border  can  be 
clearly  followed.  If  so,  we  have  to  do  with  an  enlarged  heart  ;  if  not, 
we  should  consider  pericardial  effusion.  The  outline  of  the  dark  area 
is  also  to  be  considered ;  in  pericardial  effusion  its  shape  is  rounded  ; 
that  is,  it  is  unlike  the  shadow  of  the  normal  heart. 

The  signs  which  pericardial  effusion  present  differ  with  the  amount 
of  the  effusion. 

The  larger  amounts  of  pericardial  effusion  increase  the  shadow 
of  the  cardiac  area  and  obliterate  the  pulsating  outlines  of  the  left 
border  of  the  heart,  and  the  triangle  (see  page  259)  is  of  course 
obliterated.  The  cardiac  area  should  be  studied  with  the  patient  in 
different  positions.  The  shadow  of  the  effusion  when  traced  on  the 
chest  wall  is  an  excellent  guide  for  tapping  the  pericardium,  should 
that  operation  be  required. 

Small  Effusion.  —  In  pericarditis  with  small  effusion  it  should  be 
remembered  that  the  effusion  is  largely  in  the  dependent  part  of  the 
pericardial  sac.  We  should  endeavor  to  determine  what  changes,  if 
any,  have  taken  place  in  the  cardiac  outline,  and  whether  this  outline 
is  modified  by  a  change  in  the  position  of  the  patient.  The  patient 
should  therefore  be  examined  in  different  positions. 

Sitting  Position  ;  Tube  behind  Patient  and  Screen  on  Frojit  of  CJicst ; 
Deep  Inspiration.  —  In  this  position  the  border  of  the  left  diaphragm 
would  not  be  followed  so  far  towards  the  median  line,  if  there  was  peri- 
cardial effusion,  as  in  health,  and  if  the  patient  were  inclined  to  one 
side  or  the  other  the  cardiac  outline  might  be  modified. 

Sitting  Position;  LigJit  going  throngh  from  Side  to  Side;  Deep 
Inspiration.  —  The  lower  and  posterior  border  of  the  heart  should  be 
determined,  so  far  as  possible  ;    if   the  outline   of   the  triangular  area 


OTHER   ABNORMAL   CONDITIONS   OF   THE    HEART        30 1 

formed  by  this  portion  of  the  heart  (see  pages  258  to  259)  is  not 
changed,  there  is  probably  not  much,  if  any,  pericardial  effusion 
present. 

Rcci'.uibcnt  Position ;  Deep  Inspiration.  —  An  examination  should 
also  be  made  with  the  patient  lying  on  his  back,  and  also  on  his  right 
and  left  sides,  and  with  the  light  going  through  the  body  horizontally, 
the  tube  being  on  a  level  with  the  heart,  to  determine  whether  or  not 
in  these  positions  there  is  any  modification  of  the  outline  of  the  heart. 

The  outlines  of  the  heart  and  the  effusion  should  be  drawn  during 
both  inspiration  and  expiration. 

Mobility  of  the  Heart.  —  Hoffmann  (Verhandlungen  des  Congresses 
fiir  Innere  Medicin,  1898)  has  found  that  the  hearts  in  four  cases 
of  paroxysmal  tachycardia,  which  but  for  this  condition  were  normal, 
were  surprisingly  movable  ;  the  first  moved  6  centimetres,  the  second 
5.2  centimetres,  the  third  G.J  centimetres,  and  the  fourth  5.3  centimetres. 
These  observations  are  of  much  interest. 

Hoffmann  also  found  that  the  heart  moved  to  the  left  surprisingly 
little  in  children  ;  in  ten  persons  in  the  first  and  second  decades  it  did 
not  move  more  than  1.2  centimetres;  in  grown  persons  there  was  a 
movement  of  2  to  7  centimetres. 

Murmurs.  Auscultation  and  X-Ray  Examinations. — These  two  meth- 
ods of  examination  used  together  may  enable  the  physician  to  determine 
with  unusual  exactness  the  site  of  the  murmur  on  the  heart,  if  ausculta- 
tion is  done  after  the  outline  of  this  organ  has  been  traced  on  the  chest. 
Second,  it  may  enable  him  to  recognize  that  the  disappearance  of  a 
murmur  due  to  the  enlargement  of  the  auriculo-ventricular  ring  is  coin- 
cident with  the  diminution  of  the  size  of  the  heart.  Third,  it  may  enable 
him  to  recognize  that  murmurs  which  are  present  when  the  heart  is 
pushed  out  of  place  disappear  when  the  pressure  is  relieved,  as  for 
example  in  some  cases  of  pregnancy. 

Other  conditions  of  the  heart  present  abnormal  appearances  or  outUnes 
when  examined  by  the  fluorescent  screen.     (See  Fig.  179  and  Appendix.) 

Persistence  of  the  Ductus  Arteriosus  Botalli.  —  Zinn  {Deutsche  Med. 
Woclienschrift,  No.  8,  Supplement,  pp.  41-42,  1898)  gives  a  detailed 
account  of  a  case  in  which  the  diagnosis  of  "  Persistence  of  the  Ductus 
Arteriosus  Botalli "  was  supported  by  an  X-ray  examination. 

The  writer  states  that  the  interest  of  the  case  lay  particularly  in  the 
fact  that  the  widening  of  the  pulmonary  artery  established  by  percussion 
could  be  recognized  on  the  screen  and  in  the  radiograph. 


302     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


SECTION    VI 

EFFECT   OF    TREATMENT    WATCHED    BY   X-RAY    EXAMINATIONS 

The  size  of  the  heart  may  vary  greatly  from  the  normal,  and  become 
much  enlarged,  and  yet  resume  a  smaller  size  after  rest  in  bed  and 
digitalis,  and  this  decrease  in  size  may  be  observed  by  X-ray  exami- 
nations. 

N^    ££/a.   ^.  A„     /Z       OaU     -M^-^    ^^  ■  ''^V- 

Address  Occupation  Vol.  ^/f  Page    2^0 

Diagnosis       S^^:^^^^>^^^*^ 


■  ^  ^   \AfinZC 


i-lG.  177.     Ella  H.     First  X-ray  examination.     (Cut  one-tliird  life  size.)     Both  lungs  dark  except  in 
upper  portions.      Heart  enlarged. 

Progress  of  Improvement  in  Heart  watched  by  X-Ray  Examinations 
during  Treatment.  —  Fortunately,  in  many  forms  of  cardiac  disease  we 
are  able  to  benefit  the  patient  very  much  by  suitable  treatment.     The 


TREATMENT   WATCHED    BY   X-RAY    EXAMINATIONS 


303 


improvement  is  indicated  on  the  screen  in  two  ways  :  first,  tlie  size  of 
the  heart  which  has  become  enlarged  is  seen  to  diminish  ;  and,  second, 
the  lungs  gain  in  transparency  as  the  heart's  action  becomes  stronger 
and  the  congestion  or  oedema  is  lessened. 


Name 

Address 

Diagnosis 


.J^^(a^  ^y  '97. 


Age    /2 

Occupation 


Date 


Vol. 


Page 


Fig.  178.  Ella  H.  Third  X-ray  examination.  (Cut  one-third  life  size.)  Lungs  now  clear.  Excur- 
sion of  diaphragm  (lines  not  given)  can  be  well  seen  on  both  sides.  Heart  smaller  in  size  than  on 
March  22. 

The  following  cases  illustrate  this  point :  — 

Case  I.  Ella  H.,  twelve  years  old,  entered  my  service  at  the  Boston 
City  Hospital  March  22,  1897.  Diagnosis:  endocarditis  following 
rheumatism.     Patient  complained  of  dyspnoea  and  orthopnoea. 

MarcJi  22.  X-Ray  Examination. — The  outlines  of  the  diaphragm 
could  not  be  seen,  and  the  outlines  of  the  ribs  were  indistinct  below  the 


304 


THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 


second  rib.  These  conditions  showed  marked  oedema  of  the  lungs  or 
hydrothorax  on  both  sides. 

Physical  Signs.  —  Dulness  to  percussion,  respiratory  murmur  very 
much  diminished,  and  absence  of  vocal  fremitus  on  both  sides  in  the 
lower  portion  of  the  thorax.  There  was  a  systoHc  murmur  at  the  apex, 
transmitted  to  axilla,  also  a  presystolic  roll. 

April  3.  Second  X-Ray  Examination.  —  The  size  of  the  heart  was 
the  same  as  on  March  24,  but  the  front  and  back  portions  of  the  ribs 
were  seen  in  both  chests,  and  also  the  outline  of  the  diaphragm  on 
both  sides.  That  is  to  say,  in  the  twelve  days  since  the  last  X-ray 
examination,  the  thorax  had  become  very  much  clearer.  The  excur- 
sion of  the  diaphragm  was  2.5  centimetres  on  the  right  side  and  1.5 
centimetres  on  the  left  side. 

Treatment.  —  Rest  in  bed  and  digitalis. 

April  27.  Third  X-Ray  Examination.  —  The  outline  of  the  heart 
was  smaller  than  at  the  previous  examination,  that  is,  nearer  the  normal ; 
the  excursion  of  the  diaphragm  on  the  right  side  was  5  centimetres  and 
on  the  left  side,  2.5  centimetres.  A  very  marked  improvement  in  her 
breathing  coincided  with  the  improvement  as  observed  on  the  fluores- 
cent screen. 

Case  II.  Mary  H.,  thirty-eight  years  old,  entered  my  service  at 
the  hospital  December  13,  1898.  Diagnosis:  valvular  disease  of  the 
heart. 

Physical  Examination. — There  was  a  double  murmur  at  the  apex; 
pulmonic  second  accentuated ;  and  the  width  of  the  heart  by  percussion, 
on  a  level  with  the  nipples,  was  17.5  centimetres.  There  was  slight 
oedema  of  both  legs. 

December  14.  X-Ray  Examination.  —  Both  lungs  were  very  dark; 
the  outline  of  the  heart  could  barely  be  seen  ;  no  diaphragm  could  be 
seen,  and  the  outlines  of  most  of  the  ribs  were  obscured. 

January  3,  1899.  Second  X-ray  examination  after  rest  and  treat- 
ment with  digitalis.  The  lungs  were  much  clearer,  and  the  excursion  of 
the  diaphragm  on  each  side  could  be  readily  followed. 

Hoffmann  (Verhandlungen  des  Congresses  fiir  Innere  Medicin, 
1898)  found  by  means  of  the  X-rays  that  in  some  cases  of  mitral  insufifi- 
ciency  the  width  of  the  heart  was  18  or  even  20  cm.,  and  that  in  one 
case  the  width  was  diminished  from  18  to  16  cm.  after  the  use  of  digi- 
talis, but  later  returned  to  17.2.  His  X-ray  examinations  also  showed 
that  in  normal  men,  from  twenty  to  forty  years  of  age,  the  width  of 


TREATMENT   WATCHED    BY   X-RAY    EXAMINATIONS        305 

the  heart  varied  from  14  to  15  cm.,  but  in  older  persons  the  width  was 
usually  greater. 

Avoidance  of  too  Early  Cessation  of  Treatment.  —  The  condition  of 
the  patient  may  be  so  improved  that  further  treatment  seems  unneces- 
sary, but  if  the  X-ray  examinations  show  that  the  lower  portion  of  the 
lung  is  still  dark,  the  further  use  of  digitalis  is  indicated  ;  the  remedy 
has  not  done  all  the  good  of  which  it  is  capable,  if  continued.  The  fol- 
lowing case  illustrates  this  point :  — 

Bessie  N.,  twenty-nine  years  old,  entered  my  service  at  the  hospital 
March  27,  1897.  Diagnosis:  dilated  heart  and  disease  of  the  mitral 
valve. 

History.  —  Had  dyspnoea  for  seven  months;  pain  in  the  praecordial 
region  and  over  the  left  scapula  ;  no  oedema ;  marked  orthopnoea. 

PJiysical  Examination.  —  Heart's  area  enlarged  to  the  right;  apex 
in  the  fifth  space,  8.7  centimetres  from  mid-sternum;  action  regular; 
loud  presystolic  murmur  at  apex,  with  thrill.  Examination  of  lungs 
negative. 

This  patient  had  rest  and  digitalis,  and  about  one  week  later  had 
improved  so  much  that  I  considered  the  question  of  her  transfer  to  the 
Convalescent  Home;  but  did  not  send  her,  as  an  X-ray  examination 
made  at  this  time  showed  that  the  chest  was  dark  throughout,  except  in 
the  upper  portion,  where  the  ribs  could  be  dimly  seen.  Two  weeks  later 
another  X-ray  examination  showed  improvement,  but  the  outlines  of  the 
diaphragm,  the  heart,  and  the  ribs,  could  only  be  seen  during  deep 
inspiration,  and  even  then  dimly.  This  indicated  that  a  longer  stay  in 
the  hospital  would  be  beneficial.  Without  the  X-ray  examination  she 
would  have  been  discharged  while  she  still  needed  hospital  care. 

Enlarged  Hearts  with  Murmur.  —  It  is  probable  that  a  murmur 
may  sometimes  be  due  to  the  failure  of  the  valves  to  close  on  account 
of  the  inefficiency  of  the  muscular  walls  of  the  heart,  but  it  may  disap- 
pear as  the  heart  diminishes  in  size  after  rest  and  other  suitable  treat- 
ment. An  X-ray  examination  may  enable  the  physician  to  watch  the 
heart  and  to  observe  that  it  has  become  reduced  in  size  when  the 
murmur  is  no  longer  heard. 

Warning  of  Patient's  Serious  Condition  given  by  X-Ray  Examina- 
tion.—  Bridget  O'D.,  fifty-five  years  old,  entered  my  service  at  the  hos- 
pital March  7,  1898.     Diagnosis:  myocarditis. 

March  7.  X-Ray  Examination.  —  The  pulmonary  areas  were  so 
dark  that  the  outlines  of  the  heart  could  be  seen  only  very  dimly,  and 


3o6    thp:  roentgen  rays  in  medicine  and  surgery 

the  only  diaphragm  outline  seen  was  that  on  the  right  side  and  during 
full  inspiration.  The  heart  was  much  enlarged  to  the  right.  The  con- 
dition shown  by  this  examination  was  a  warning  to  put  the  patient  on  the 
list  of  those  very  dangerously  ill.     She  died  suddenly  on  March  13. 

Timely  Warning  of  Disease.  —  X-ray  examinations  of  the  heart  warn 
the  physician,  in  cardiac  as  well  as  renal  diseases,  of  the  serious  condi- 
tion that  his  patient  is  approaching,  and  point  out  to  him  the  necessity 
for  the  timely  use  of  remedies  to  supplement  the  insufficient  action  of 
the  heart.  Want  of  clearness,  especially  in  the  lower  portion  of  the 
lung,  will  indicate  early  that  suitable  treatment  is  required. 

Mr.  S.,  fifty-eight  years  old,  was  sent  to  me  from  out  of  town  for 
consultation  and  X-ray  examination.  His  physician  wrote  to  me  as  fol- 
lows, "  Patient  suffering  from  some  form  of  thoracic  disease,  probably 
an  emphysematous  condition  with  some  complications." 

History.  —  Asthma ;  marked  dyspnoea  on  exertion ;  a  rapid  and 
irregular  heart. 

X-Ray  Exmninatioii.  —  Both  pulmonary  areas  so  much  darker  than 
in  health  that  it  was  far  more  difificult  than  usual  to  determine  the  size 
of  the  heart.  The  heart  seemed  enlarged.  I  advised  that  he  should  be 
taken  back  to  his  home,  which  was  some  miles  from  Boston,  with  extreme 
care,  and  be  put  to  bed.  I  also  advised  suitably  large  doses  of  digitalis, 
and  that  its  effects  should  be  carefully  watched. 

Two  weeks  later  his  physician  wrote  me  as  follows  :  "  The  patient 
grew  steadily  worse  and  took  to  his  bed  the  day  after  our  visit  to  you. 
Every  symptom  was  very  grave,  to  say  the  least.  Heart  failure  was 
expected  at  any  time,  and  many  pulsations  of  the  heart  were  lost  at  the 
wrist.  Respiration  of  the  worst  character.  Delirium  continuous.  After 
a  week,  the  patient  improved.  The  lungs  cleared  up  wonderfully  well, 
and  the  heart  and  pulse  came  together.     Orthopnoea  had  disappeared." 

A  later  report  from  this  physician  stated  that  the  patient  had  resumed 
his  business. 

The  X-ray  examination  was  undoubtedly  of  service  in  this  case,  giv- 
ing immediate  and  unequivocal  evidence  of  the  conditions  present,  and 
imparting  to  me  convictions  as  to  the  treatment  that  should  be  pursued, 
and  that  this  treatment  should  be  carried  out  courageously. 

Want  of  Efficient  Pulmonary  Circulation  shown  by  X-Ray  Exami- 
nations. —  (See  Fig.  179.)  The  X-rays  may  be  useful  in  indicating  how 
much  increase  in  density  there  may  be  in  the  lungs,  due  to  passive  con- 
gestion, or  to  oedema,  without  either  giving  rise  to  well-marked  signs  by 


TREATMENT   WATCHED    BY   X-RAY    EXAMINATIONS 


2>o7 


auscultation  and  percussion.  In  certain  diseases  or  conditions  of  the 
valves  of  the  heart  the  pulmonary  circulation  may  be  so  much  obstructed 
that  the  lungs  are  found  radioscopically  to  be  much  darkened,  even  more 
so  than  the  diagram  represents.  This  should  warn  us  to  take  suitable 
care.     In  X-ray  examinations  we  have  a  new,  useful,  and  dehcate  means 


Fig.  179.     Diagram  of  passive  congestion  ot  tlie  lungs  from  valvular  disease. 
In  valvular  disease  I  have  seen  much  darker  lungs  than  the  diagram  indicates  become  clear,  and 
the  dyspnoea  cease  after  treainient  by  digitalis. 

of  recognizing  changes  in  the  pulmonary  circulation,  due  to  abnormal 
conditions  of  the  lungs,  heart,  or  kidneys. 

Alcoholics.  —  I  have  observed  in  a  number  of  cases  that  the  lungs 
of  patients  addicted  to  the  use  of  alcohol  were  less  bright  throughout 
than  normal,  and  in  a  few  that  there  was  a  marked  contrast  between 


308     THE    ROKNTGEX    RAVS    IX    MKDICIXE    AXD   SURGERY 

the  pulmonarv  area  above  the  position  of  the  diaphragm  in  expiration 
and  the  portion  seen  between  the  two  positions  of  the  diaphragm  in  full 
inspiration  and  expiration,  this  latter  portion  being  much  brighter  than 
that  above  the  expiratory  diaphragm  line.  The  lack  of  brightness  in 
the  lungs  may  be  due  to  a  pulmonary  congestion,  which  would  make 
these  organs  appear  darker  on  the  screen  than  in  health  ;  or  there  may 
be  some  other  explanation  of  this  condition. 

In  one  patient,  who  was  thirty-four  years  old,  and  had  been  drinking 
to  excess  for  two  weeks,  and  had  been  exposed  to  cold  in  the  month  of 
March,  the  excursion  of  the  diaphragm  on  the  right  side  was  7.5  centi- 
metres, and  on  the  left  7  centimetres ;  above  the  point  reached  by  the 
diaphragm  during  expiration,  on  both  sides,  the  lungs  were  uniformly 
denser  than  normal,  so  dense  that  the  ribs  were  scarcely  visible,  but 
below  this  point,  during  full  inspiration,  the  pulmonary  area  was  bright 
on  both  sides.  The  right  side  of  the  heart  was  much  enlarged.  This 
patient  had  no  physical  signs  by  auscultation  and  percussion  except  that 
the  note  by  percussion  was  less  clear  than  in  health.  The  increase  in 
the  size  of  the  heart  was  not  found  by  percussion. 

Passive  Congestion  shown  to  be  Absent  by  X-Ray  Examination. — 
On  the  other  hand,  we  may  be  assured  that  there  is  no  passive  con- 
gestion in  the  lungs  in  some  cases  of  cardiac  disease  in  which  we 
suspect  this  condition,  if  an  X-ray  examination  shows  normal  brightness 
of  the  pulmonary  areas. 

Louis  C,  twenty-six  years  old,  a  patient  of  Dr.  Horace  D.  Arnold, 
came  to  the  medical  out-patient  department  of  the  Boston  City  Hospital 
on  March  5,  1898,  complaining  of  gastric  symptoms  and  palpitation, 
with  pain  in  the  cardiac  region. 

Physical  examination  at  this  time  gave  a  mitral  systolic  murmur  at 
the  apex  in  the  nipple  line. 

On  January'  7,  1899,  his  symptoms  were  more  marked.  Apex  in  the 
sixth  space  in  the  nipple  line  ;  both  presystolic  and  systolic  murmurs 
present. 

Ftbniary  11.  The  signs  and  symptoms  continued.  It  was  a  ques- 
tion whether  or  not  there  was  a  passive  congestion  of  the  lungs. 

February  14,  1899.  I  found  by  X-ray  examination  that  this  condition 
was  not  present,  as  the  lungs  were  perfectlv  clear. 

Precautionary  and  Preventive  X-Ray  Examinations.  —  The  following 
case  illustrates  the  advantage  of  such  examinations  :  — 

\Vm.  A.  H.,  twentv'-nine  years  old.     This  patient,  having  joined  a  1 


TREATMENT   WATCHED    BY   X-RAY    EXAMINATIONS       309 

party  which  was  bound  for  the  Klondike,  came  to  see  me  as  a  precau- 
tionary measure  to  learn  whether  or  not  he  was  sound  in  body. 

I  found  that  he  had  a  much  enlarged  heart,  and  that  he  was  wholly 
unfit  for  packing  over  the  steep  trail  beyond  Skaguay,  for  example 
(the  railway  had  not  then  been  built),  and  for  undertaking  life  in  such 
a  country. 

Many  middle-aged  men  of  large  affairs  and  great  energy  doubtless 
overtax  their  hearts  in  various  ways.  As  a  consequence,  they  are 
obliged  to  retire  from  active  work  before  many  years  ;  or  the  end  comes 
suddenly.  It  would  be  better  if  more  persons  in  our  country  would 
follow  the  custom  of  some  of  my  patients,  and  go  to  a  physician  to  be 
examined  once  a  year.  This  custom  is  more  useful,  even,  than  for- 
merly, for  by  means  of  X-ray  examinations  we  are  able  to  give  earlier 
warning  of  some  diseases  of  the  chest  than  has  hitherto  been  possible. 


CHAPTER   XI 

THORACIC    AiNEURISMS 

Appearances  seen  on  the  Fluorescent  Screen  and  by  X-Ray  Photo- 
graph in  Aneurisms.  —  The  appearances  vary  greatly  and  depend  on 
the  size  and  position  of  the  aneurism. 

A  small  aneurism  of  the  descending  arch  of  the  aorta  casts  a  shadow 
to  the  left  of  the  sternum  and  above  the  heart,  and  by  localization  would 
be  found  to  be  in  the  posterior  rather  than  the  anterior  part  of  the 
chest.     (See  Fig.    i8o.) 

An  aneurism  of  the  ascending  aorta  would  usually  cast  a  shadow 
to  the  right  of  the  sternum,  and  by  localization  would  be  found  nearer 
the  anterior  than  the  posterior  chest  wall. 

A  large  aneurism  casts  a  shadow  on  both  sides  of  the  sternum  ;  the 
heart  is  often  seen  to  be  more  or  less  displaced,  or  enlarged. 

Difficulty  of  Diagnosis  by  Ordinary  Methods ;  Need  of  X-Ray  Exami- 
nations.—  The  diagnosis  of  an  aneurism  is  often  difficult  and  sometimes 
impossible  by  the  ordinary  methods.  Aneurisms  are  not  infrequently 
overlooked  in  their  early  stages,  the  time  when  there  is  the  best  oppor- 
tunity for  prolonging  life ;  or,  if  recognized,  their  extent  is  not  appre- 
ciated ;  or  their  presence  is  suspected  when  they  do  not  exist.  Therefore, 
in  order  to  get  as  accurate  a  knowledge  as  possible  of  the  condition  of 
the  thoracic  cavity,  the  chest  should  be  examined  by  means  of  the 
fluorescent  screen,  both  in  front  and  behind,  and  from  side  to  side. 
An  X-ray  photograph  may  also  be  of  service.  Pulsations  can  be  seen 
only  by  means  of  the  screen.  If  the  walls  of  the  aneurism  are  thick 
and  the  sac  is  filled  with  a  dense  clot,  there  may  be  no  pulsation.  (See 
case  of  D.,  page  327.)  On  the  other  hand  it  is,  I  suppose,  possible  for 
a  dense  body  near  the  normal  aorta  to  have  a  movement  imparted  to  it 
by  the  pulsations  of  that  blood  vessel. 

Method  of  Examination  by  the  X-Rays.  —  The  spinal  column  should 
be  examined  to  see  if  there  is  any  displacement  of  the  vertebrae  which 

310 


THORACIC    ANEURISMS  31 1 

might  push  the  aorta  to  one  side  ;  for  if  through  disease  in  the  vertebrae 
or  some  neighboring  part  the  descending  aorta  is  pushed  a  Httle  to  the 
left,  this  condition  might  be  confounded  with  an  aneurism,  if  this  pos- 
sibility were  not  in  mind  and  this  region  carefully  examined.      If  there 


FIG.  180.  Diagram  of  an  aneurism  of  the  descending  aorta.  Full  inspiration.  The  aneurism 
would  often  be  higher  in  the  chest  than  is  shown  in  this  diagram.  A  dilatation  of  the  ascending 
arch  of  the  aorta  would  usually  cast  a  shadow  on  the  right  side  of  the  sternum.  Broken  lines  show 
position  of  diaphragm  in  expiration.    The  heavy  lines  under  the  axillae  indicate  the  level  of  the  nipples. 

is  disease  of  the  spine,  producing  displacement  of  the  aorta,  a  careful 
X-ray  examination  of  the  line  of  the  vertebrae  would  reveal  the  cause 
of  the  unusual  position  of  this  artery. 

Moreover,  in  some  healthy  individuals  the  aorta  is  more  prominent 
than  in  others.     I  have  examined  some  persons  in  whom  there  was  no 


312     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

trace  of  aneurismal  dilatation,  but  in  whom  the  outUne  and  even  the 
pulsation  of  the  descending  arch  of  the  aorta  could  be  followed. 

If  any  departure  from  the  normal  outlines  is  found  in  this  portion 
of  the  thorax,  the  physician  should  determine  whether  or  not  the 
abnormal  outline  is  due  to  something  which  is  nearer  the  front  or  the 
back  of  the  chest.  This  point  may  be  ascertained  by  making  two 
examinations  of  the  patient,  one  with  the  fluorescent  screen  on  the 
front,  and  the  other  with  the  screen  on  the  back  of  the  chest ;  or 
the  screen  may  be  in  a  constant  position  and  the  patient  may  be  exam- 
ined with  the  tube  in  two  different  positions,  about  60  centimetres  apart. 
(See  Chapter  III,  page  81.)  The  outlines  seen  on  the  screen  should 
be  traced  on  the  skin,  or  celluloid  covering  the  screen.  (See  Chapter 
III,  pages  77-81,  for  directions  for  making  and  recording  the  observations 
made.)     An  X-ray  photograph  should  also  be  taken,  as  stated  above. 

Further,  we  may  be  assisted  to  distinguish  between  new  growths  in 
the  thorax  and  an  aneurism.  For  this  purpose  a  careful  determination 
of  the  position  of  the  outlines,  not  only  laterally  but  antero-posteriorly, 
is  important.  If,  for  example,  when  examining  the  chest,  a  small 
shadow  is  seen  on  the  fluorescent  screen  in  the  neighborhood  of  the 
descending  arch  of  the  aorta  on  the  left  of  the  sternum,  the  physician 
must  determine  whether  it  is  cast  by  something  situated  in  the  front  or 
back  of  the  chest.  As  a  rule,  an  aneurism  of  the  ascending  portion  of 
the  aorta  will  be  found  nearer  the  front  of  the  chest  than  the  back ; 
whereas  aneurisms  of  the  descending  aorta  in  the  early  stages  would  be 
found  nearer  the  posterior  portion  of  the  chest  than  the  anterior.  If 
pulsation  of  the  outline  is  seen,  we  probably  have  to  do  with  an  aneu- 
rism, though  it  is  possible  that  a  movement  might  be  given  to  a  new 
growth  situated  over  the  aorta.  Whether  or  not  this  variation  from  the 
normal  is  due  to  a  new  growth  or  to  an  aneurism  cannot  always,  of 
course,  be  determined  by  the  X-rays  alone.  They  furnish  only  one  way, 
though  a  very  valuable  way,  of  studying  this  region. 

Other  Means  of  Diagnosis.  —  The  history  of  the  case  should  also  be 
carefully  considered ;  the  patient's  age ;  the  symptoms,  and  their  dura- 
tion ;  for  while  in  some  cases  the  diagnosis  of  an  aneurism  can  be  made 
with  much  certainty  with  the  aid  of  the  X-rays,  it  may  in  others  be  difficult 
to  recognize  the  cause  of  the  abnormal  outline  found  by  means  of  the 
fluorescent  screen. 

Early  Diagnosis  Possible  by  X-Rays.  —  In  general,  it  may  be  said 
that  aneurisms  of  the  thoracic  aorta  may  be  seen  by  the  X-rays  before 


THORACIC   ANEURISMS  313 

there  are  physical  signs.  Furthermore,  where  it  is  desirable  to  be  sure 
that  no  thoracic  aneurism  exists,  the  X-ray  examination  can  render  much 
service.  There  are  patients  who  have  troublesome  symptoms,  or  signs 
such  as  dyspnoea,  paralysis  of  the  left  vocal  cord,  pain  in  the  chest,  and 
dulness  to  percussion  over  an  area  which  might  easily  be  the  site  of  an 
aneurism ;  these  symptoms  may  give  the  physician  much  anxiety  if  he 
is  led  to  consider  that  they  are  due  to  this  cause.  For  example,  in  a 
patient  in  whom  Dr.  G.  A.  Leland  found  paralysis  of  the  left  vocal  cord, 
my  X-ray  examination  showed  no  aneurism.  Later,  Dr.  Leland  informed 
me  that  the  paralysis  of  the  cord  had  disappeared.  In  these  cases  it  is 
a  satisfaction  to  the  patient  and  to  the  physician  to  be  able  to  exclude 
the  presence  of  an  aortic  aneurism,  and  we  may  be  quite  sure  that  no 
aneurism  is  present  if  the  X-rays  give  normal  outlines  in  the  thoracic 
cavity  when  careful  examination  of  the  patient  in  various  positions  has 
been  made,  including  of  course  the  triangular  space  behind  and  below 
the  heart.  Herein  lies  one  of  the  advantages  of  this  method  of  exami- 
nation. It  may  give  us  better  assurance  of  the  absence  of  an  aneurism 
of  the  aorta  in  suspected  cases  than  any  other  evidence  at  our  command. 

Cases  of  aneurism  may  give  physical  signs  suggestive  of  tuberculosis, 
neuralgia,  or  oesophageal  stricture.  The  cases  given  below  illustrate 
some  of  these  points. 

In  a  series  of  41  cases  I  examined  37  because  an  aneurism  was  sus- 
pected and  4  to  determine  the  size  of  the  heart.  Of  these  41,  16  gave 
normal  outlines  in  the  region  where  an  aneurism  had  been  suspected  ; 
6  had  more  or  less  dilatation  of  some  portion  of  the  aortic  arch,  and  19 
had  typical  aneurisms.  Seventeen  of  these  aneurisms  had  their  seat  in 
the  aortic  arch.  The  seventeenth  case  had  also  a  second  aneurism  of 
the  innominate  artery  ;  the  eighteenth  case  had  two  aneurisms,  one  in 
the  innominate  and  another  in  the  subclavian  artery  ;  the  nineteenth  had 
an  aneurism  in  the  subclavian  artery.  In  9  of  these  19  cases  there  were 
no  physical  signs  of  aneurism. 

Aneurism  suggesting  Pulmonary  Tuberculosis.  —  Case  I.  M.  J.,  a 
man  aged  fifty-nine  years,  brought  to  me  October,  1896,  by  Dr.  M.  P. 
Smithwick,  illustrates  the  increased  accuracy  in  diagnosis  that  an  X-ray 
examination  may  afford.  The  great  size  of  the  sac  seen  on  the  fluores- 
cent screen  suggested  early  rupture,  and  therefore  a  frank  statement  of 
the  case  was  made  to  the  patient  and  gratefully  received  by  him,  as  he 
was  thus  given  an  opportunity  for  a  much-needed  arrangement  of  busi- 
ness affairs. 


314 


THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 


Family  History.  —  Father  died  of  consumption  at  seventy-two  years 
of  age.  It  was  usual  for  the  males  of  the  paternal  branch  of  the 
family  to  develop  this  disease  after  fifty-nine  years.  Mother  died  of 
apople.xy.  The  patient,  his  family,  and  his  physician  did  not  doubt  that 
he  was  following  the  family  tradition  and  developing  tuberculosis.  It 
was  not  surprising  that  the  mistake  should  be  made,  when  we  com- 
pare the  clinical  picture  of  haemoptysis  and  cough  with  the  physical 
examination,  which  gave  rales  at  the  left  apex.  The  husky  voice  led 
one  to  suspect  laryngeal  tuberculosis. 


Fig.  i8i.  Case  I.  M.  J.  Reproduction  of  photograph  of  X-ray  outlines  drawn  on  chest. 
X-ray  examination  showed  a  large  thoracic  aneurism.  Family  history  and  symptoms  suggested  tuber- 
culosis.    Dotted  line,  cardiac  area  as  determined  by  percussion,  full  line  inside  as  found  by  X-rays. 

Previous  History.  —  Always  "  short-winded."  About  four  years  ago 
he  suddenly  became  unconscious  for  about  a  minute.  There  was  no 
warning,  and  recovery  was  immediate.  About  June  15,  1896,  he  began 
to  be  hoarse  and  grew  rapidly  worse,  and  had  some  cough.  About  this 
time,  while  running  after  some  colts,  he  had  marked  dyspnoea.  This 
symptom  increased,  although  he  could  walk  a  distance  if  careful.  On 
July  15  he  first  raised  a  little  blood,  rather  dark  in  color,  and  this  occurred 
from  time    to  time  afterward,  especially  after  talking.       Four  or  five 


THORACIC  anf:urisms  315 

times  after  October  i  he  had  short  and  sharp  attacks  of  pain  that  started 
in  the  "  pit  of  the  stomach  "  and  radiated  to  left  shoulder  and  down  left 
arm  to  elbow.  There  was  numbness  of  the  left  arm  associated  with  this 
pain. 

Physical  Examination.  —  The  voice  is  shrill  and  husky.  Examination 
of  the  larynx  by  Dr.  Leland  shows  the  left  cord  paralyzed  and  fixed  in 
median  line.  The  arteries  are  quite  resistant  and  nodular,  and  some- 
what tortuous.  The  heart  area  is  decidedly  diminished,  action  is  regular 
and  fairly  strong.  Apex  beat  in  sixth  interspace  apparently  outside  of 
the  nipple.  The  aortic  first  sound  is  rough;  second  sound  is  ringing 
and  valvular.  Lungs:  resonance  somewhat  exaggerated.  Over  upper 
left  chest,  resonance,  respiratory  murmur,  vocal  fremitus,  and  voice  sounds 
somewhat  exaggerated,  especially  in  front.  At  left  apex  and  to  second 
rib  in  front  are  numerous  fine  moist  rales.  A  faint  pulsation  is  to  be 
felt  by  pressing  the  chest  between  the  two  hands.  It  seems  most  marked 
at  the  junction  of  the  second  rib  with  the  sternum. 

X-ray  examination  zvith  screen  made  October,  1896,  showed  that  the 
patient  had  a  large  thoracic  aneurism,  as  indicated  in  Fig.  181.  Some 
weeks  later,  after  returning  from  a  drive,  death  occurred  suddenly. 
There  was  profuse  arterial  hemorrhage  from  the  mouth.  Failure  to 
observe  necessary  precautions  may  have  hastened  the  end. 

Aneurism  of  Aorta,  with  Perforation  into  (Esophagus ;  Aneurism  and 
Size  of  Heart  as  determined  by  X-Ray  Examination  confirmed  at  Au- 
topsy.—  This  case  should  remind  us  that  an  aneurism  ought  to  be 
excluded  before  we  dilate  a  supposed  oesophageal  stricture. 

Case  II.  E.  H.  was  admitted  to  the  service  of  Dr.  George  G.  Sears 
at  the  Boston  City  Hospital  June  13,  1898.  Diagnosis:  aneurism  of 
the  aorta.  He  was  brought  to  me  for  X-ray  examination  June  17th. 
The  following  history  was  given  :  family  history  was  negative.  Past 
history  :  neither  syphilis  nor  rheumatism ;  alcohol  in  moderation. 

Prescjit  Illness.  —  Slight  pain  began  in  cardiac  region  five  months 
ago ;  a  month  later  it  was  felt  in  front  of  right  chest ;  and  two  weeks 
later  just  to  right  of  spinal  column  at  level  of  lower  angle  of  scapula; 
it  was  a  dull  ache  and  has  persisted  and  increased  in  these  three  places; 
cough  increases  the  pain  but  full  inspiration  does  not ;  on  swallowing, 
pain  begins  at  level  of  thyroid  and  extends  along  the  spine  to  lower 
dorsal  region ;  solids  are  regurgitated  occasionally ;  meat  causes  severe 
pain  unless  finely  minced;  no  cough  or  palpitation ;  dyspnoea  and  hoarse- 
ness for  three  weeks. 


3l6     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

Physical  Exaiuiiia/ion.  —  Left  vocal  cord  partially  paralyzed  ;  pul- 
monary resonance  good,  being  slightly  exaggerated  over  right  front ; 
respiration  harsh  and  wheezy ;  on  full  inspiration  sounds  much  pro- 
longed on  right  side ;  cardiac  area  extends  from  mid-sternum  to  nipple 
line ;  sounds  normal ;  apex  in  fifth  interspace ;  pulsations  seen  over 
greater  part  of  sternum  ;  radial  pulse  regular,  good  strength  and  vol- 
ume ;  no  oedema  of  extremities ;  urine  normal.  Diagnosis  of  aneurism 
of  aorta. 


EH, 


Fig.  182.     Case  II.     E.  H.     Tracing  of  aneurism  of  aorta.      .Aneurism  and  size  of  heart  seen  by 
X-rays  confirmed  at  autopsy.     (Cut  1  one-third  original  size.) 


X-Ray  ExainiJiation.  —  Figure  182  gives  the  outline  of  the  aneurism 
seen  on  the  fluorescent  screen,  as  well  as  the  left  border  of  the  heart, 
which  border  was  much  nearer  the  median  line  than  Dr.  Sears  and  I 
had  placed  it  by  percussion.  The  X-ray  examination  showed  that  the 
heart  was  smaller  than  normal,  and  this  fact  was  confirmed  by  the 
autopsy. 

Three  weeks  after  admission  patient  raised  a  pint  of  dark  blood. 
Two  days  later  felt  unable  to  swallow  solids  or  liquids,  and  after  two 
more  days  the  stools  were  tarry.      Died.     A  post-mortem  examination 

1  The  cuts  of  the  aneurisms  are  reproductions  of  the  tracings  made  by  means  of  the  fluo- 
rescent screen.  I  have  not  attempted  to  give  reproductions  of  X-ray  photographs,  as  such 
reproductions  are  so  often  unsatisfactory. 


THORACIC   ANEURISMS  317 

was  made  by  Dr.  F.  B.  Mallory,  and  I  quote  a  part  of  the  record. 
"  Intestines  contain  dark  material.  In  posterior  wall  of  transverse  arch 
of  aorta,  3  millimetres  below  beginning  of  left  subclavian  artery,  is  an 
opening  12x18  millimetres.  This  opening  is  directly  connected  with  a 
reddish-gray  clot  projecting  through  anterior  wall  of  oesophagus  by  an 
opening  4x5  centimetres,  with  thin,  retracted,  dark  greenish  edges. 
Lower  border  of  oesophageal  perforation  is  on  level  with  bifurcation 
of  trachea.  The  opening  communicates  with  a  thin-walled  cavity 
4x7x8  centimetres,  filled  with  dark  clotted  blood  in  laminae.  Intima 
of  aorta  everywhere  thickened.  Many  elevated  yellowish  placques. 
No  areas  of  softening  nor  calcification.  Weight  of  heart  270  grammes. 
Valves  and  cavities  normal.  Some  fatty  degeneration  of  muscle  micro- 
scopically.    Lungs  very  oedematous." 

"  Anatomical  Diagnosis.  —  General  arterio-sclerosis.  Aneurism  of 
aorta  with  perforation  into  oesophagus." 

The  shadow  of  the  aneurism  was  a  little  larger  than  the  aneurism 
itself  seen  after  death,  but  during  life  the  sac  may  have  been  distended, 
and  therefore  larger  than  it  was  at  the  autopsy. 

Subclavian  Aneurism;  X-Ray  Examination  before  Operation  to  ex- 
clude Extension  below  Clavicle.  The  Result  of  this  Examination  confirmed 
by  Autopsy.  —  Before  ligating  the  subclavian,  carotid,  or  innominate 
arteries  for  aneurism,  it  is  manifestly  desirable  to  know  the  extent  of 
the  aneurism,  and  whether  or  not  there  is  also  an  aneurism  of  the  aorta. 
In  the  following  case  the  innominate  artery  was  ligated  by  Dr.  George 
W.  Gay,  and  the  case  was  reported  by  him  in  the  Boston  Medical  and 
Surgical  Journal,  July  22,  1897. 

Case  III.     A.  McC,  widow,  thirty-nine  years  of  age. 

To  determine  the  lower  boundary  of  the  aneurism  and  to  ascertain 
if  the  aortic  arch  were  involved.  Dr.  Gay  referred  the  case  to  me  for 
X-ray  examination,  with  diagnosis  of  fusiform  aneurism  of  the  innomi- 
nate, subclavian,  and  carotid  arteries. 

X-ray  examination  with  screen  showed  the  outline  of  the  portion  of 
the  aneurism  above  the  clavicle,  and  demonstrated  that  there  was  no 
extension  of  the  aneurism  below  the  clavicle,  and  that  the  lungs  were 
normal.     The  X-ray  examination  was  confirmed  by  the  autopsy. 

Diagnosis  of  Aneurism  confirmed  by  X-Ray  Examination. 

Case  IV.  C.  S.,  a  patient  in  my  service  at  the  Boston  City  Hospital, 
a  house  painter,  thirty-six  years  old,  had  a  well-defined  aneurism  of  the 
aorta,  but  no  history  of  dyspnoea. 


3l8     THE   ROENTGEN   RAVS   IN    MEDICINE   AND   SURGERY 

History. — Syphilis  eighteen  years  ago;  well  until  eight  months  ago, 
when  dull  pain  with  occasional  paroxysms  of  sharp  pain  began  in  front 
of  chest,  in  left  arm  to  the  elbow,  and  later  shot  up  left  side  of  back  of 
neck  and  head.  The  pain  has  been  constant  from  the  beginning,  and 
nine  weeks  ago  became  so  excruciating  that  he  was  compelled  to  cease 
working.  No  weakness  or  tenderness  of  the  arm;  hoarse  five  or  six 
weeks  ;  no  dyspnoea  ;  constipated  ;   appetite  poor. 


Fig.  183.  Case  IV.  C.  S.  Cut  of  X-ray  tracing.  The  greater  portion  of  the  aneurism  is  to  the 
left  of  the  sternum,  though  it  also  e.vtends  to  the  right  side.  The  excursion  of  the  diaphragm  on 
the  left  side  is  much  less  than  on  the  right.     (Cut  one-third  life  size.) 


Physical  Examinatioii.  —  Well  developed  and  nourished;  voice  high- 
pitched  ;  pupils  equal  and  reactions  normal ;  no  paralysis  of  ocular 
muscles  ;  neither  wrist  nor  toe  drop ;  grasp  normal ;  lead  line  present. 
Tracheal  tug ;  radial  pulses  alike ;  cardiac  area  and  sounds  normal 
except  in  second  interspace  to  left  of  sternum,  where  first  sound  is  pro- 
longed and  second  sound  slightly  accentuated  ;  at  apex  of  left  lung  in 


THORACIC   ANEURISMS 


19 


front,  to  third  rib,  and  behind  to  spine  of  scapula,  vocal  resonance  and 
fremitus  are  diminished  ;  no  rales ;  on  full  inspiration  right  side  of  the 
chest  is  the  more  expansive.  Laryngoscopic  examination  by  Dr.  Leland 
showed  right  vocal  cord  normal,  left  paralyzed. 

X-ray  examination  by  me  showed  a  well-defined  dark  area  in  upper 
left  chest,  extending  out  from  the  aorta  and  expanding  with  every  heart- 
beat. The  excursion  of  the  diaphragm  on  the  left  side  was  much 
diminished  as  compared  with  the  right. 


EM 


© 


Fig.  184.  Case  V.  E.  M.  Cut  of  X-ray  tracing.  June  8,  first  X-ray  examination.  Small 
aneurism  indicated  by  full  line  enclosing  shaded  area.  September  8,  second  X-ray  examination. 
Increase  of  aneurism  indicated  by  full  lines  marked  "  Sept.  8."     (Cut  one-third  original  size.) 


Aneurism  suggesting  Intercostal  Neuralgia ;  suspected  Aneurism 
confirmed  by  X-Ray  Examination.  These  Examinations  enable  us  to 
determine  whether  an  Aneurism  is  or  is  not  increasing. 

Case  V.  E.  M.,  thirty-three  years  of  age,  referred  to  me  by 
Dr.  J.  J.  Putnam  for  X-ray  examination  with  reference  to  aneurism. 
Patient  had  suffered  with  what  appeared  to  be  severe  intercostal 
neuralgia  for  which  an  operation  had  been  done.  The  pain  was  in  his 
left  arm,  left  side,  and  below  the  ribs.  It  had  been  severe  for  two 
months,  sometimes  by  day,  but  especially  at  night.  There  was  a  his- 
tory of  syphilis. 

X-j-ay  examination  made  June  8,  1897,  showed  a  small  aneurism  of 
the  descending  portion  of  the  aortic  arch,  which  is  indicated  in  the 
tracing  (Fig.    184)  by  the  shaded    lines  of    the  inner  outline  marked 


320     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

June  8.  A  second  X-ray  examination  made  September  8,  1897,  gave 
the  outline  marked  in  the  tracing  September  8,  which  demonstrated 
that  the  aneurism  was  increasing.  Later  the  physical  signs  of  aneurism 
became  well  marked,  the  pulsation  being  easily  palpable,  and  finally 
the  aneurism  ruptured. 

Extent  of  Aneurism  determined  only  by  X-Ray  Examination.  —  The 
following  case  illustrates  well  how  definitely  we  may  outline  an  aneu- 
rism in  the  chest  by  means  of  the  X-rays,  and  shows  that  a  considerable 
amount  of  dilatation  of  the  descending  arch  of  the  aorta  may  give  rise 
to  no  physical  signs. 


Fig.  185.  Case  VI.  Aneurism  of  aorta  in  James  L.,  thirty-three  years  old.  Broken  line  shows 
outline  of  aneurism  by  percussion.  Full  line  shows  X-ray  outline  of  aneurism  and  heart.  The  part 
of  the  aneurism  to  the  left  of  the  sternum  was  not  indicated  by  percussion.  The  horizontal  line  near 
the  nipples  shows  position  of  diaphragm  in  expiration  (broken  line)  and  in  full  inspiration  (full  line) 
by  X-ray  examination.     (Cut  one-third  life  size.) 


Case  VI.     James  L.,  thirty-three  years  old. 

This  patient  was  under  the  care  of  Dr.  J.  L.  Morse,  and  the  diag- 
nosis of  thoracic  aneurism  was  made  by  the  usual  methods,  but  its 
extent  was  revealed  only  when  he  was  brought  to  me  for  an  X-ray 
examination,  as  until  that  was  made  the  dilatation  of  the  aorta  to  thf* 
left  of  the  sternum  was  unrecognized,  and  could  not  have  been  recog. 
nized  by  ordinary  physical  examination. 


THORACIC    ANEURISMS 


321 


Diagnosis  of  Aortic  Aneurism  by  X-Ray  Examination  confirmed  by 
Autopsy.  Position  of  Left  Border  of  Heart  obtained  by  X-Ray  Examina- 
tion confirmed  at  Autopsy. 

Case  VII.  A  man  forty-five  years  old  was  brought  to  me  for 
examination,  from  the  out-patient  department,  by  Dr.  Arnold,  on 
February  18,  1899,  with  diagnosis  of  probable  aneurism  of  the  innomi- 
nate artery  and  possible  aneurism  of  the  aorta. 


T  Y 


Fic.  186.  Case  VII.  The  full  and  broken  curved  lines  indicate  the  outlines  of  the  aneurism  and 
the  heart  in  inspiration  and  expiration  respectively  as  determined  by  X-ray  examination ;  the  dotted 
lines,  the  outlines  as  determined  by  percussion.  The  autopsy  confirmed  the  correctness  of  the  X-ray 
examination.  The  full  and  broken  parallel  lines  indicate  the  position  of  the  diaphragm  in  inspiration 
and  expiration.     (Cut  one-third  life  size.) 

TJie  X-ray  era i/ii nation  made  February  18  revealed  a  small  aneu- 
rism of  the  descending  portion  of  the  aortic  arch,  which  gave  no  signs 
by  auscultation  and  percussion,  even  after  the  X-ray  examination. 

On  February  23  the  patient  was  found  on  the  street  unconscious, 
was  brought  into  my  service  at  the  hospital,  and  a  few  moments  later 
died.  No  cause  of  death  was  discovered  by  Dr.  Pearce  at  the  post- 
mortem, but  the  autopsy  showed  a  small  aneurism  of  the  descending 


32  2     THE    ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 

portion  of  the  aortic  arch  corresponding  to  the  outline  drawn  at  the 
X-ray  examination,  likewise  an  aneurismal  dilatation  of  the  innominate 
artery,  neither  of  which  had  ruptured. 

It  will  be  seen  by  comparing  the  X-ray  lines  with  the  dotted  lines, 
which  represent  the  outlines  found  by  percussion,  that  we  failed  to 
recognize  any  dulness  over  the  site  of  the  aneurism,  and  even  after  I 
had  seen  its  outline  on  the  fluorescent  screen  we  could  not  detect  it  by 
percussion.  Further,  by  following  the  dotted  line  which  indicates  the 
left  border  of  the  heart  as  found  by  percussion,  we  see  that  it  is  incor- 
rect when  compared  with  the  same  border  as  determined  by  the  fluorescent 
screen  and  at  the  autopsy. 

Another  point  of  interest  in  this  patient  is  that  the  lungs  were 
found  to  be  normal  both  by  the  X-ray  and  post-mortem  examinations. 

Aneurism  unsuspected  by  Physical  Examination ;  determined  by 
X-Ray  Examination. 

Case  VIII.  J.  McC,  a  man  forty  years  old,  referred  to  me  from 
the  out-patient  department  by  Dr.  Arnold,  March,  1899,  illustrates  some 
cases  of  the  class  in  which  aneurism  could  not  be  made  out  on  physi- 
cal examination,  and  was  recognized  in  the  X-ray  examination  made  to 
determine  the  size  of  the  heart. 

History.  —  Syphilis  eleven  years  ago  ;  rheumatism  six  years  ago ; 
alcohol  habitually. 

Present  Ilhiess.  —  Marked  dyspnoea  on  exertion  and  at  times  vertigo; 
very  nervous  and  sleeps  poorly  ;  pain  at  times  in  the  left  shoulder  and 
breast ;  visible  pulsations  of  all  large  arteries ;  capillary  pulse  ;  heart 
dulness  begins  below  third  rib  and  extends  2  centimetres  to  right 
of  sternum ;  apex  in  sixth  interspace,  3  centimetres  outside  nipple 
line  ;  double  murmurs  over  aortic  area  ;  similar  murmurs  at  apex,  which 
are  transmitted  toward  axilla;  diastolic  murmur  heard  over  epigastrium 
and  systolic  over  large  areas  in  back  ;  diffuse  visible  pulsation  over 
cardiac  area. 

X-ray  exaviination  revealed  with  unusual  clearness  a  small  aneurism 
of  the  descending  arch  of  the  aorta,  and  its  pulsations  were  easily  seen 
on  the  screen.  Two  examinations  were  made,  with  an  interval  of  three 
weeks  between  them,  and  the  outline  of  the  aneurism  was  readily 
observed  ;  most  clearly  when  the  fluorescent  screen  was  placed  on  the 
patient's  back,  over  the  upper  part  of  the  left  scapula.  Dr.  John  W. 
Bartol  kindly  brought  the  patient  to  me  on  April  15  and  June  3,  1899. 
We  found  no  change  from  the  previous  X-ray  examination. 


1 


THORACIC   ANEURISMS 


0^3 


Aneurism  unrecognized  by  Auscultation  and  Percussion  seen  by  an 
X-Ray  Examination. 

Case  IX.  E.  D.,  a  neurasthenic  woman,  forty-two  years  old, 
referred  to  me  from  the  nervous  out-patient  department  of  the 
Boston  City  Hospital  by  Dr.  P.  C.  Knapp,  after  the  throat  department 
had  reported  to  him  complete  paralysis  of  the  left  recurrent  laryngeal 
nerve.  It  is  interesting  to  note  that  the  hoarseness,  which  led  to  sus- 
picion of  aneurism,  had  made  no  impression  on  the  patient,  because 
she  had  been  somewhat  hoarse  since  early  school  days.  Patient  has 
suffered  from  nervousness  for  three  years ;  lately  easily  tired,  emotional, 


A.B 


Fig.  187.  Case  X.  A.  B.  Cut  of  X-ray  tracing.  Aneurism  of  descending  portion  of  aortic 
arch,  recognized  only  by  X-ray  examination.  Full  line  partially  enclosing  shaded  area  indicates 
aneurism. 


and  depressed.  Hoarseness  has  increased  since  she  has  become  emo- 
tional.    Some  dyspnoea  recently. 

PJiysical  Examination.  —  Auscultation  and  percussion  gave  no  signs 
of  aneurism. 

X-ray  examination  with  screen  revealed  a  small  aneurism  of  the 
aorta. 

Aneurism  recognized  only  by  an  X-Ray  Examination. 

Case  X.  A.  B.,  referred  to  Dr.  Leland  for  oesophageal  stricture, 
and  sent  by  him  to  me  for  an  X-ray  examination  in  March,  1898. 

History.  —  In  twenty-two  years  of  married  life  her  only  pregnancy 
resulted  in  a  miscarriage.  Patient  was  said  to  have  a  stricture  about 
2  centimetres  below  the  upper  end  of  the  oesophagus,  and  another  about 


324     THE    ROENTGEN    RAVS    IN    MEDICINE   AND    SURGERY 

opposite  the  second  rib.  During  the  past  summer  her  family  physician 
had  passed  an  oesophageal  bougie  every  third  day.  Shortly  before 
coming  to  me  this  treatment  had  been  omitted  and  she  felt  no  worse. 

Physical  examination  gave  no  sign  of  thoracic  aneurism. 

X-ray  examination  revealed  what  was  probably  a  small  aneurism  of 
the  descending  portion  of  the  aortic  arch.  Its  outline  was  plain  whether 
viewed  from  front  or  behind. 

This  case  suggests  the  advisability  of  an  X-ray  examination  before 
dilatation  for  oesophageal  constriction  in  some  cases. 

Aneurism  suspected  on  account  of  Hoarseness,  but  there  was  no 
Paralysis  of  the  Left  Recurrent  Laryngeal  Nerve  ;  X-Rays  showed  no 
Aneurism  was  Present.  — As  is  well  known,  hoarseness  may  be  the  first, 
and  for  a  long  time  the  only,  sign  of  thoracic  aneurism.  This  symptom 
was  present  in  the  following  case,  and  it  was  therefore  referred  to  me 
for  an  X-ray  examination. 

Case  XI.  B.  D.,  forty-five  years  old,  came  to  the  throat  depart- 
ment of  the  Boston  City  Hospital  on  January  17,  1900,  to  consult  Dr. 
Leland,  to  whom  he  gave  the  following  history  :  — 

Six  weeks  previously  he  first  noticed  a  marked  hoarseness  of  voice, 
and  that  a  considerable  effort  was  necessary  to  phonate.  There  were 
no  other  symptoms.  His  family  history  and  personal  history  were  both 
negative. 

Careful  examination  with  tJie  fluorescent  screen  did  not  reveal  any- 
thing abnormal  in  any  portion  of  the  thoracic  aorta. 

Subsequent  examination  of  the  larynx  by  Dr.  Leland  showed  the 
arytenoid  on  the  right  side  to  be  absolutely  immobile,  both  in  respiration 
and  phonation  ;  the  rigJit  vocal  cord  was  also  involved.  Pupils  equal ; 
no  glands  demonstrable;   no  physical  signs  or  symptoms  of  aneurism. 

On  subsequent  inquiry  in  June,  1900,  the  patient  reported  that  his 
voice  was  completely  restored. 

Case  XII.  Tentative  Diagnosis  of  Thoracic  Aneurism. — The 
hospital  record  in  the  case  of  O.  D.  is  given  below,  and  my  X-ray 
examination  follows :  — 

Thomas  O.  D.,  thirty-three  years  of  age.  Patient  of  Dr.  Metcalt 
of  Winthro]:),  Mass. 

Family  History.  —  Father  and  one  brother  died  of  cramps.  Three 
sisters  and  mother  living. 

Past  History. — Never  been  sick  before  December,  1899,  when  he 
complained  of  hoarseness.     Admitted  to  military  hospital.      Diagnosis: 


THORACIC    ANEURISMS  325 

perichondritis;  not  relieved.  Was  readmitted,  April  20,  1900,  com- 
plaining of  constant  cough  in  addition  to  his  hoarseness.  Discharged 
Mav  13,  improved.  No  tubercle  bacilli  found;  no  loss  of  weight;  no 
ph}sical  examination  recorded. 

Last  admission,  June  9.  Loss  in  weight  25  pounds  since  June  9. 
Normal  weight  190  pounds. 

Present  History.  —  Still  complains  of  hoarseness  with  violent  cough. 
I'vula  much  relaxed  ;  was  amputated.  Temperature  on  admission  102°, 
which  next  day  fell  to  normal.     Has  had  an  occasional  night  sweat. 

PJiysical  Examination.  —  Examination  of  chest  showed  a  displace- 
ment of  the  heart  to  the  right.  Apex  beat  not  felt,  but  was  loudest  in 
fifth  interspace,  1.25  centimetres  to  left  of  right  nipple.  Percussion  of 
cardiac  area  showed  dulness  to  right  of  sternum  ;  left  lung  dull  through- 
out. Breathing  diminished,  but  not  absent.  Loud  rales  over  upper 
left  back.  Vocal  and  tactile  fremitus  both  absent  over  entire  left  lung. 
Expectoration  profuse  for  a  few  days,  apparently  pure  pus.  Micro- 
scopic examination  for  tubercle  bacilli  negative;  test  with  tuberculin 
negative. 

Since  admission,  expectoration  has  practically  ceased.  Heart  re- 
mains displaced  to  right  of  sternum  ;  dulness  over  left  lung  still  per- 
sistent ;  bronchial  rales  much  diminished  and  often  absent;  breathing 

I  still    diminished,  but   present;    vocal  fremitus    still    much    diminished; 

I  tactile  f remntus  also  diminished,  but  present,  with  the  exception  of  left 
front,  where  it  is  practically  absent. 

I        Pain  in  right  shoulder  behind,  going  down  to  elbow  and  hand  at 

I  times.     Tactile  fremitus  increased  over  right  chest,  upper  half. 

!  A  definite  diagnosis  was  not  made,  but  another  physician,  who  saw 
him  in  consultation,  was  inclined  to  think  it  was  tuberculosis. 

'  My  X-ray  examination,  given  below,  inclined  me  to  the  diagnosis  of 
aneurism,  but  there  was  so  unusual  a  history  that  I  desired  to  watch  the 
patient  still  further  before  making  a  definite  diagnosis.  This,  however, 
could  not  be  done,  as  the  patient  left  the  State. 

X-Ray  Examination  xvitJi  Screen. — The  full  line,  marked  A,  in 
the  tracing,  is  an  outline  of  the  aneurism,  this  portion  of  which  the 
X-rays  showed  to  be  nearer  the  posterior  than  the  anterior  chest  wall ; 
this  outline  does  not  move  even  in  deep  inspiration.  The  full  and 
broken  lines,  marked  B  and  C  respectively,  outline  the  aneurism  on 
the  right  in  inspiration  and  expiration,  and  the  X-rays  showed  that  this 
portion  was  nearer  the  front  than  the  back  of  the  thorax.     All  the  full 


326     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


lines  in  the  tracing  indicate  the  outlines  seen  during  a  deep  inspiration, 
and  the  broken  lines  those  seen  in  expiration.  Contrary  to  the  usual 
rule  in  health,  the  heart  in  deep  inspiration  moved  downward  and  to 
the  left  instead  of  downward  and  to  the  right.  Further,  when  the 
heart  moved  toward  the  right  in  expiration,  the  added  portion  of  the 
outline  A,  indicated  in  the  tracing  by  a  broken  Hne,  was  brought  into 
view.     That  is  to  say,  the  heart  lies  in  front  of  the  aneurism,  and  is 


XC 


Fig.  i88.  Case  XII.  O.  D.  Cut  of  tracing  made  with  screen  on  front  of  chest.  X-ray  examina- 
tion shows  the  outlines  of  what  proved  to  be  an  aneurism,  and  that  it  was  nearer  the  back  than  the 
front  of  the  chest.     (Cut  one-third  life  size.) 


drawn  upward  and  to  the  right  in  expiration,  but  is  pulled  out  of  this 
abnormal  position  by  the  descent  of  the  diaphragm. 

The  subsequent  history,  obtained  some  time  later,  was  as  follows :  On 
September  13,  1900,  the  patient  went  to  a  baseball  game;  on  his  return 
home  he  coughed  up  a  quantity  of  blood,  and  died  in  a  few  minutes. 

Information  obtained  at  Autopsies  of  Cases  of  Aneurism  in  Regard  to 
Heart  confirmed  by  X-Rays.  —  The  cases  of  aneurism  that  I  have  exam- 


THORACIC   ANEURISMS 


127 


ined  have  afforded  several  opportunities  to  confirm  by  autopsy  the 
correctness  of  the  position  of  the  left  border  of  the  heart  as  determined 
by  X-ray  examination,  and  to  show  that  that  obtained  by  percussion  was 
incorrect.     The  following  case  and  Case  VII  are  illustrative  :  — 

Aneurism  of  Ascending  Aorta ;  Enlarged  Heart ;  X-Ray  and  Percussion 
Lines  compared ;  X-Ray  Outlines  confirmed  by  Autopsy. 

Case  XIII.  D.  This  patient  was  seen  by  Dr.  Arnold  in  the  out- 
patient department  and  sent  to  the  hospital ;  he  entered  my  service  and 


Fig.  189.  Case  XIII.  D.  Aneurism  of  the  ascending  aorta  without  pulsation.  X-ray  and  per- 
cussion lines  compared.  X-ray  lines  confirmed  at  autopsy;  also  the  density  of  the  lung  that  was 
determined  by  X-ray  examination.     (Cut  one-third  life  size.) 

was  examined  carefully,  both  by  the  usual  physical  examination  and 
radioscopically,  and  the  outlines  of  the  heart  and  of  the  aneurism,  as 
determined  by  each  method,  were  compared.  The  following  cut  gives  a 
reduced  copy  of  the  outlines  as  determined  by  the  X-rays  and  by  per- 
cussion ;  the  full  lines  indicate  the  former,  the  dotted  lines  the  latter. 

At  the  autopsy,  which  took  place  a  few  days  later,  and  at  which  I 
was  present,  the  correctness  of  the  X-ray  outlines  was  confirmed.  The 
position  of  the  right  and  left  borders  of  the  heart  and  of  the  aneurism 


328     THE    ROENTGEN    RAVS    IN    iMEDICINE   AND    SURGERY 

was  determined  by  Dr.  Mallory,  by  measurements  taken  directly  after 
the  removal  of  the  sternum  and  the  opening  of  the  pericardium.  The 
tracing  of  the  outlines  made  at  the  X-ray  examination  was  in  my  hand, 
and  it  was  found  that  these  outlines  agreed  with  Dr.  Mallory's  measure- 
ments. Four  millimetres  abov^e  the  cusp  of  the  aortic  valve  there  was 
an  opening  2  X  2.75  centimetres  in  the  anterior  surface  of  the  aorta, 
rather  to  the  left  side.  This  communicated  with  a  sac  having  very 
thick  walls,  which  was  filled  with  a  dense  clot.  The  aneurism  was 
unruptured.  There  was  marked  fatty  degeneration  of  the  heart.  The 
condition  of  the  left  lung  as  noted  at  the  X-ray  examination  was  also 
confirmed,  it  being  found  somewhat  denser  than  normal,  especially  at 
its  upper  portion. 

This  case  is  one  in  which  the  aneurism  did  not  threaten  the  patient's 
life,  as  shown  by  the  autopsy.  The  dense  tissue  surrounding  the 
aneurism  and  its  sac  being  filled  with  a  firm,  hard  clot,  made  it  unlikely 
that  the  aneurism  would  have  increased  further  in  size.  X-ray  exam- 
inations made  at  intervals  in  such  cases  would  demonstrate  that  the 
aneurism  was  not  increasing,  and  that  interference  with  it  by  the  intro- 
duction of  wires  or  horse  hair  was  not  indicated. 

If  the  conditions  were  reversed,  and  the  aneurism  was  increasing, 
the  X-ray  examination  would  also  indicate  this  fact. 

Importance  of  Fluorescent  Screen  and  Careful  Interpretation  of  X-Ray 
Photograph.  —  The  difficulties  which  present  themselves  in  the  diagno- 
sis of  thoracic  aneurisms,  where  X-ray  examinations  are  not  used,  or  if 
used  are  not  properly  interpreted,  is  illustrated  very  well  by  a  case 
published  in  the  American  Journal  of  tJie  Medical  Sciences  in  1900. 

This  woman  presented  herself  at  a  hospital  in  June,  1898,  seeking 
treatment,  as  she  said,  for  an  aneiu'isni.  She  had  a  tumor  extending 
through  the  upper  portion  of  the  sternum.  The  tumor  was  soft  and 
elastic,  and  pulsated  with  every  heart  beat,  the  pulsation  being  slightly 
expansile,  and  causing  the  apex  of  the  tumor  to  rock  slightly  from 
side  to  side.  .  .  .  Below  this  tumor,  at  the  level  of  the  third  and 
fourth  costal  cartilages,  was  a  second  pulsating  mass,  larger,  flatter, 
and  less  inflamed  than  the  other.  This  mass  was  in  the  median  line, 
and  covered  an  area  as  large  as  the  palm  of  the  hand.  The  upper 
tumor  broke  on  the  third  day,  and  a  small  quantity  of  bloody  puriform 
material  escaped,  reducing  the  size  of  the  mass  at  least  one-third. 
The  lower  swelling  was  opened  and  material  like  that  from  the  upper 
mass  was  evacuated.      She  improved  and  was  sent  to  a  convalescent 


THORACIC   ANEURISMS  329 

home,  returning  to  the  out-patient  department  some  weeks  later.  Three 
physicians  who  had  seen  the  patient  agreed  that  there  was  no  aneurism 
present.  An  X-ray  photograph  was  taken  at  this  time,  but  no  indica- 
tion of  an  aneurism  was  observed  on  the  radiograph. 

On  the  evening  of  September  15  she  went  to  bed  feehng  as  usual. 
At  midnight  she  got  up.  There  was  the  sound  of  a  gush  and  a  cry. 
Her  husband  found  her  dead  in  a  pool  of  blood  issuing  from  her  chest. 

Her  physician's  frank  comment  is  as  follows  :  — 

"  The  accompanying  radiographs  should  have  prevented  the  mistake 
in  diagnosis.  But  I  am  ashamed  to  say  that  none  of  those  who  saw  her 
took  a  sufficiently  intelligent  interest  in  them  to  see  their  significance 
until  it  was  too  late. 

"We  looked  at  them  solely  for  evidence  as  to  perforation  of  the 
sternum.  Finding  no  gap  in  the  sternum  shadow,  the  false  inference 
was  drawn  that  no  such  perforation  was  present.  But  we  should  have 
known  that  the  position  of  the  spinal  column  is  such  that  perforations 
of  the  sternum,  even  of  considerable  size,  do  not  show  on  a  radiographic 
plate. 

"  It  is  perfectly  easy  now  to  see  that  there  is  a  tumor  in  the  region 
of  the  aortic  arch,  and  to  distinguish  the  heart  and  the  hver  below. 
But  somehow,  this  did  not  force  itself  upon  us  at  that  time.  The 
moral  obviously  is  that  we  should  know  more  about  the  interpretation 
of  radiographic  plates." 

I  refer  to  this  case  because  the  question  is  put  forcibly  and  clearly. 
If  we  desire  to  secure  the  advantages  which  the  X-ray  examinations 
afford  in  cases  of  aneurism,  we  must  not  only  take  pains  to  get  good 
radiographs,  but  we  must  also  teach  ourselves  how  to  interpret  them. 
Further,  if  this  patient  had  been  examined  with  the  fluorescent  screen, 
a  good  apparatus  being  used,  instead  of  by  means  of  a  photographic 
plate,  the  aneurism  could  not  have  been  overlooked. 

Recently  I  have  seen  in  consultation  a  few  patients,  where  a  diag- 
nosis of  thoracic  aneurism,  based  on  an  X-ray  examination,  had  been 
made  by  the  examining  physicians,  in  whom  I  found  a  perfectly  normal 
thorax  by  X-ray  examination.  And  further,  I  have  had  my  attention 
directed  to  cases  in  which  a  diagnosis  of  an  aneurism  was  made  by  the 
attending  physicians,  but  no  aneurism  was  found  at  the  autopsy.  These 
occurrences  have  led  me  to  go  over  my  own  cases  carefully  with  refer- 
ence to  their  subsequent  history,  and  in  no  case,  so  far  as  I  can  ascer- 
tain, has  any  patient  in  whom    I   have    found  no  aneurism  by  X-ray 


330     THE    ROENTGEN    RAYS    IN    MEDICINE    AND   SURGERY 

examination  proved  later  to  have  one.  On  the  other  hand,  all  the  cases 
in  which  I  have  made  the  definite  diagnosis  of  aneurism  by  X-ray  exam- 
ination, and  in  which  I  have  been  able  to  get  the  subsequent  history, 
have  either  died  of  what  was  undoubtedly  the  rupture  of  an  aneurism ; 
or,  if  death  ensued  from  some  other  disease,  and  a  post-mortem  was 
made,  an  aneurism  has  been  found  corresponding  in  position  and  size 
to  that  found  by  my  X-ray  examination.  The  partial  exception  to  this 
statement  is  the  case  of  Mr.  C,  given  in  the  chapter  on  New  Growths. 
The  cause  of  death  was  a  mass  of  glands  below  the  sternum,  which  gave 
rise  to  outlines  very  similar  to  some  aneurisms.  I  saw  the  patient  only 
once.  The  examination  was  not  as  complete  as  I  desired,  and  I  found 
it  difficult  to  decide  whether  the  appearances  were  due  to  a  new  growth 
or  to  an  aneurism,  but  inclined  to  the  latter  diagnosis.  As  stated  in  the 
chapter  on  New  Growths,  I  expected  to  see  the  patient  again,  get  his- 
tory, and  make  a  further  examination.  But  the  expectation  was  not 
fulfilled. 

I  do  not  mean  to  suggest  that  I  might  not  find  it  impossible  to  make 
a  definite  diagnosis  in  some  cases,  but  I  believe  this  would  now  occur 
infrequently. 

In  conclusion,  X-ray  examinations  should  be  made  both  with  the 
fluorescent  screen  and  the  X-ray  photograph.  Normal  outlines  in  the 
upper  part  of  the  chest  give  us  the  best  assurance  that  an  aneurism  of 
the  aorta  is  not  present,  though  symptoms  may  obtain  which  lead  the 
physician  to  suspect  it.  On  the  other  hand,  if  an  aneurism  be  present, 
its  outline  will  be  demonstrated  by  the  X-ray  examination.  An  outline 
suggestive  of  aneurism  may  be  due  to  other  causes,  as  a  new  growth, 
for  example.  But  confusion  of  this  kind  is  not  common,  and  we  can  in 
most  cases  convince  ourselves  by  a  careful  examination  whether  or  not 
it  is  an  aneurism  which  casts  the  shadow.  X-ray  examinations  enable 
us  to  determine  the  extent  of  an  aneurism  much  more  accurately  than 
the  usual  physical  examination,  and  to  detect  its  existence  at  a  much 
earlier  stage.  Successive  X-ray  examinations  enable  us  to  determine 
whether  or  not  it  is  increasing. 

To  make  a  definite  diagnosis  of  aneurism  by  the  usual  physical 
examination  we  may  be  obliged  to  wait  for  the  development  of  marked 
signs,  and  this  delays  treatment.  On  the  other  hand,  if  the  physician 
begins  treatment  because  the  signs  are  suspicious,  he  runs  the  risk  of 
subjecting  his  patient  to  an  unnecessary  regimen.  The  advantages  of 
an  X-ray  examination  when  compared  with  the  usual  physical  examina- 


THORACIC    ANEURISMS  331 

tion  are  evident.  A  definite  diagnosis  can  be  made  in  most  cases 
before  there  are  physical  signs.  Treatment  can  therefore  be  begun  at 
an  earlier  and  more  hopeful  stage,  can  be  planned  more  intelligently, 
as  the  knowledge  of  the  position  and  extent  of  the  aneurism  is  more 
accurate,  and  its  results  can  be  better  estimated  because  we  can  more 
accurately  measure  any  change  in  size.  In  cases  like  that  of  D.,  page 
327,  the  physical  signs,  not  only  the  X-ray  signs,  would  be  found  early 
because  of  the  position  of  the  aneurism,  which  was  directly  under  the 
sternum.  The  X-ray  examination  should  of  course  be  considered  in 
connection  with  the  history  and  all  other  evidence  when  making  a 
diagnosis. 

An  operation  should  not  be  performed  on  an  aneurism  near  the 
thoracic  aorta  until  the  latter  artery  has  been  examined  by  the  X-rays, 
for  if  an  aortic  aneurism  exists,  operation  would  be  unadvisable. 


CHAPTER    XII 

NEW  GROWTHS.     ENLARGED  GLANDS.     ABSCESS  AND  GANGRENE 

OF  LUNG 

New  growths  in  the  bone  may  as  a  rule  be  easily  recognized  bv  the 
X-rays,  as  for  example  an  osteosarcoma  or  an  exostosis,  but  as  these 
growths  will  be  considered  under  the  surgical  uses  of  the  rays,  we  need 
not  discuss  them  here,  but  will  take  up  directly  those  that  occur  in  the 
thorax. 

A  new  growth  in  the  lung  usually  casts  a  marked  shadow,  and  in  the 
latter  stages  may  fill  up  most  of  one  side  of  the  chest  and  thus  render 
this  side  completely  dark  on  the  fluorescent  screen.  If,  however,  the 
new  growth  is  recognized  in  its  early  stage,  the  shadow  cast  may  be 
slight.  In  many  cases  an  X-ray  examination  makes  it  evident  without 
much  question  that  we  have  to  deal  with  a  new  growth,  although  in 
some  at  least  its  presence  was  unsuspected  by  the  usual  methods. 
There  are  other  cases  in  which  the  disease  has  advanced  so  far  before 
the  patients  are  examined  by  the  X-rays  as  to  involve  a  large  part  or 
the  whole  of  one  lung,  and  in  such  cases  the  appearances  seen  on  the 
screen  may  well  at  first  sight  call  to  mind  pleurisy  with  large  effusion 
or  an  unresolved  pneumonia.  There  are  still  other  cases  in  which  a  new 
growth,  under  certain  conditions,  may  simulate  a  thoracic  aneurism. 
Therefore,  if  the  interpretation  of  the  appearances  seen  on  the  screen 
is  not  perfectly  plain,  the  patient  should  be  examined  with  the  X-rays 
going  through  the  body  from  different  directions;  and  in  certain  cases 
an  X-ray  photograph  should  be  taken. 

Likewise  it  must  be  remembered  that  the  X-ray  examination  is  only 
one  method,  and  that  its  results  are  to  be  considered  in  connection  with 
the  history  of  the  patient,  his  present  condition,  and  ^he  evidence 
obtained  by  other  means  of  physical  examination  ;  but  I  have  no  doubt 
that,  as  we  learn  better  how  to  make  and  how  to  interpret  X-ray  exam- 
inations, they  will  aid  us  to  make  a  more  definite  and  an  earlier  diagnosis, 
when  it  is  a  question  of  a  new  growth,  than  has  hitherto  been  possible. 

On  the  other  hand,  when  a  patient  has  been  examined   by  the  ordi- 


NEW   GROWTHS.     ENLARGED    GLANDS  333 

nary  methods,  and  the  case  does  not  sccdi  to  be  obscure,  although  the 
symptoms  observed  are  not  wholly  characteristic  of  those  produced  by 
a  new  growth,  or  the  diagnostic  picture  obtained  is  incomplete,  an 
X-rav  examination  should  be  made  for  confirmation  or  refutation  of 
the  diagnosis. 

The  points  just  touched  upon  can  be  most  clearly  appreciated  by 
the  history  of  a  few  cases  and  the  accompanying  cuts. 

The  first  case  illustrates  the  method  of  locating  a  new  growth  :  — 

Daniel  M.,  thirty-nine  years  old,  came  to  the  out-patient  department 
of  the  Boston  City  Hospital  on  January  26,  1899,  and  was  under  the 
care  of  Dr.  John  L.  Ames. 

History.  —  On  January  9  the  patient  raised  a  little  dark  blood. 
Had  some  diarrhoea  and  passed  two  spoonfuls  of  dark  blood.  He 
weighed  165  pounds. 

Present  Ilbiess.  —  The  general  appearance  of  the  patient  was  good. 
The  physical  examination  showed,  at  the  right  back,  beginning  about 
the  middle  of  the  scapula,  an  area  of  dulness  about  the  size  of  the  palm 
of  the  hand,  which  did  not  extend  to  the  base  of  the  lung.  Over  this 
area  the  respiratory  and  vocal  sounds  were  somewhat  diminished. 
The  fremitus  was  about  the  same  on  both  sides.  There  were  no  rales. 
At  the  right  apex  in  front  there  was  no  dulness,  but  respiration  was 
broncho-vesicular  in  character.      Expiration  was  prolonged  and  harsh. 

On  January  28,  1899,  the  patient  was  sent  to  me  for  an  X-ray  exam- 
ination with  reference  to  early  pulmonary  tuberculosis.  The  radio- 
scopic  examination  showed  in  the  right  chest  a  dark  and  sharply  defined 
area  with  a  rounded  outhne,  about  15  centimetres  high  and  12  centi- 
metres wide.  There  was  a  space  of  about  2.5  centimetres  between 
the  lower  border  of  the  dark  area  and  the  diaphragm  during  deep 
inspiration,  and  during  expiration  the  curve  of  the  diaphragm  over- 
lapped the  lower  portion  of  the  dark  area  in  such  a  way  as  to 
indicate  that  during  this  period  of  the  respiratory  movement  the 
lower  portion  of  the  mass  intervened  between  the  dome  of  the  dia- 
phragm and  the  posterior  wall  of  the  chest.  I  then  examined  the 
thorax  from  different  points  of  view  in  order  to  determine  the  exact 
position  of  this  dark  area,  and  I  found  it  was  situated  nearer  the  back 
than  the  front  of  the  chest.  This  position  was  demonstrated  in  several 
ways,  and  the  following  description  and  cuts  show  the  method  pursued, 
and  that  accurate  information  can  be  obtained  in  some  cases  by  the 
fluorescent  screen. 


334 


THE    ROENTGEN    RAVS    IN    MEDICINE   AND    SURGERY 


Method  of  Examination. — (See  also  Chapter  III,  pages  81-86.) 
When  the  patient  was  lying  on  his  face,  and  the  screen  was  placed  on 
his  back  and  the  tube  below  him,  the  outline  of  the  dark  area  was  more 
sharply  defined  than  when  the  respective  positions  of  the  screen  and 
tube  were  reversed,  which  showed  that  the  dark  area  was  nearer  the 
posterior  than  the  anterior  wall  of  the  chest. 

Line3  dracuj]  oj)  .Sc^cH 


Fig.  190.  Daniel  M.  Cut  of  tracing  made  with  patient  lying  on  liis  face,  the  screen  on  his  back. 
and  the  tube  below  the  stretcher.  The  shaded  area  indicates  the  dark  mass;  the  full  line  enclosing 
it,  its  outline  and  position  during  expiration;  the  dotted  lines,  its  outline  and  position  during  full 
inspiration  ;  the  full  line  in  the  lower  part  of  cut  and  the  broken  line  parallel  to  it,  the  position  of  the 
diaphragm  in  full  inspiration  and  expiration  respectively. 

This  cut  includes  only  the  right  back;  the  median  line  is  shown,  and  at  its  upper  end  the  spinous 
process  of  the  seventh  cervical  vertebra  is  indicated.      (Cut  one-third  life  size.) 

Second,  when  the  screen  was  on  the  front  of  the  chest,  and  the  tube 
behind  the  patient,  the  shadow  moved  through  a  greater  distance  dur- 
ing deep  inspiration  than  when  the  respective  positions  of  the  screen 
and  tube  were  reversed  ;  which  again  showed  that  the  darkened  area 
was  nearer  the  posterior  than  the  anterior  wall  of  the  chest.  Further, 
with  the  screen  on  the  front  of  the  chest  the  shadow  of  the  lower  edge 


NEW    GROWTHS.     ENLARGED    GLANDS 


135 


of  the  mass  moved  a  greater  distance  in  full  inspiration  than  the  upper 
edge ;  which  showed  that  the  lower  edge  was  nearer  the  posterior 
part  of  the  chest  wall  than  the  upper  edge.  In  full  inspiration  the 
shadow  of  the  lower  edge  moved  2.5  centimetres,  and  that  of  the  upper 
edge  a  little  less. 


BoniffM 


JVecudroiulh  in  J^/c/t/  Luna 
LiJiei  r/m/on  un  JronI  0/  Cfiejf' 


Fig.  191.  Daniel  M.  Cut  of  tracing  made  with  patient  lying  on  his  back,  the  screen  on  the  front 
of  his  chest,  and  the  tube  below  the  stretcher.  Shaded  area  indicates  the  new  growth  ;  the  full  curved 
line  above  and  below  it,  its  outline  and  position  in  expiration;  the  dotted  lines,  in  full  inspiration. 
The  other  full  lines  indicate  the  outline  and  position  of  the  heart  and  diaphragm  in  full  inspiration ; 
the  broken  lines,  in  expiration.     (Cut  one-third  life  size.) 

By  comparison  with  Fig.  190,  it  will  be  seen  that  the  shadow  of  the  lower  border  of  the  dark  mass 
move  farther  when  the  screen  is  on  the  front  of  the  chest  than  when  it  was  on  the  back.  As  the  dis- 
tance of  the  tube  from  the  screen  was  the  same  in  both  cases,  it  is  evident  that  the  mass  casting  the 
shadow  was  nearer  the  screen  when  it  was  on  the  back  than  when  it  was  on  the  front  of  the  chest. 


Third,  when  the  tube  was  placed  somewhat  behind  and  to  the  right 
of  the  patient,  so  that  the  X-rays  fell  upon  the  chest  at  a  point  between 
the  axillary  lines  (screen  on  front),  the  front  of  the  chest  was  clear  ; 
which  again  showed  that  the  shadow  seen  was  not  due  to  a  mass  in  the 
front  of  the  chest. 


336     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

Several  X-ray  examinations  were  made  of  this  patient,  but  the  accom- 
panying tracings  represent  the  appearances  seen  on  the  fluorescent 
screen  at  one  of  these  examinations  only.  In  Fig.  191  the  outline  of 
the  heart  and  diaphragm  is  indicated  by  a  full  line  in  deep  inspira- 
tion, and  by  a  broken  line  in  expiration  ;  and  the  outline  of  the  new 
growth  by  a  full  line  in  expiration  and  a  dotted  line  during  inspiration. 
The  first  tracing  (see  Fig.  190)  is  copied  from  the  lines  which  were 
drawn  on  the  back  of  the  chest,  the  patient  lying  on  his  face  (the  oval 
at  the  top  of  the  median  line  indicates  the  position  of  the  spinous  pro- 
cess of  the  seventh  cervical  vertebra) ;  the  second  (see  Fig.  191 )  from  the 
lines  drawn  on  the  front  of  the  chest ;  and  the  third,  a  small  tracing 
(see  Fig.  192),  from  the  lines  drawn  on  the  right  side  of  the  chest  during 
a  deep  inspiration. 


Danjp/M. 
Lwej  JjYiiun  on  flight  .J/^e 
(Junnc  Jf/f/  Jn^^Pii  z///on 

Fig.  192.  Daniel  M.  Cut  of  tracing  made  from  patient  with  the  screen  on  his  right  side  and  the 
tube  opposite  the  left  side,  showing  the  outline  of  the  bright  area  seen  when  he  was  examined  in  this 
position  during  full  inspiration.  In  health  this  area  has  the  shape  of  a  spherical  triangle  (see  Chapter 
X,  on  Heart,  page  259).  In  this  patient  the  limit  of  the  upper  part  of  the  bright  area  was  formed  by 
the  dark  mass;  the  lower  limit  of  this  area  corresponded  to  that  foimd  in  health.  D  represents  the 
line  of  the  diaphragm  in  full  inspiration  ;  H,  the  lower  and  posterior  border  of  the  heart;  S,  the  parts 
just  anterior  to  the  spine;   ?,  the  lower  border  of  the  growth. 

When  the  patient  was  examined  in  the  latter  position,  that  is  to  say, 
with  the  light  going  through  the  body  from  side  to  side,  and  the  fluores- 
cent screen  on  the  right  side,  instead  of  the  usual  spherical  triangle 
(see  Fig.  158  in  chapter  on  Heart)  outlined  by  the  diaphragm  below,  the 
heart  in  front  and  above,  and  posteriorly  by  what  I  have  called  the 
"spine,"  although  strictly  speaking  the  shadow  is  not  cast  by  the  spine 
itself,  but  rather  by  what  lies  in  front  of  it,  I  found  a  figure  defined  by 
four  curved  sides,  the  convex  side  of  all  four  lines  being  inward.  The 
lowest  of  these  curves  is  a  portion  of  the  diaphragm,  the  anterior  one 
the  lower  posterior  border  of  the  heart,  the  posterior  one  the  spine,  and 
the  upper  one  a  portion  of  the  new  growth. 


NEW   GROWTHS.     ENLARGED    GLANDS  2)j7 

The  reader  must  imagine  the  patient  with  all  these  lines  drawn  on 
his  skin  (they  are,  of  course,  readily  removed  with  a  little  alcohol),  in 
order  to  appreciate  how  the  examinations  made  from  different  sides  con- 
firmed each  other,  and  gave  an  exact  indication  of  the  size,  position,  and 
movement  of  the  dark  mass. 

The  X-ray  photograph  (Fig.  193)  was  taken  somewhat  later  than  the 
tracings  ;  it  shows  the  rounded  border  of  the  dark  new  growth,  and 
below  the  growth  the  lighter  pulmonary  area  crossed  by  the  ribs  on 
both  the  anterior  and  posterior  wall  of  the  chest ;  likewise  in  its  lower 
portion  the  outline  of  the  diaphragm  and  the  liver.      I  have  had  only  a 


Fig.  193.  Daniel  M.  Radiograph  taken  with  plate  on  front  of  chest  and  tube  behind  the  back. 
The  curved  outline  of  the  dark  mass  above  the  light  area  corresponds  to  the  outline  seen  on  the 
fluorescent  screen  (Fig.  192,  page  336).  Below  the  light  area,  which  is  crossed  by  the  ribs  on  front  and 
back  of  thorax,  is  seen  a  portion  of  the  diaphragm.     (About  one-third  size  of  original.) 

portion  of  the  outline  of  the  new  growth  reproduced  in  the  cut,  for  if 
the  whole  had  been  included  a  greater  reduction  of  scale  would  have 
been  necessary  than  was  advisable. 

The  striking  features  of  this  case  are,  first,  the  fact  that  so  large  a 
mass  in  the  thorax  should  give  such  slight  physical  signs;  and,  second, 
the  readiness  with  which  its  outlines,  position,  and  movement  could  be 
followed  on  the  fluorescent  screen. 

The  well-defined,  rounded  outline  of  the  mass  suggested  an  aneu- 
rism, but  an  aneurism  of  this  extent  would  be  accompanied  by  some 
well-marked  changes  in  the  heart,  and  these  were  not  present ;  also  the 
position  of  the  heart  would  be  lower  down  in  the  chest,  whereas  there 
z 


338     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

was  only  a  slight  displacement  of  this  organ  to  the  left.  Therefore  the 
diagnosis  suggested  by  the  first  appearances  would  not  be  borne  out  by 
the  other  observations. 

The  three  tracings  and  radiograph  are  given  to  show  how  we  may 
determine,  not  only  the  size,  but  the  position,  of  a  new  growth  in  the 
chest  more  exactly  by  an  X-ray  examination  than  by  other  methods. 


JacoS  D 
^arco/7W  of  Lona^ 


Fig.  194.    Jacob  D.    Cut  of  tracing  made  with  screen  on  front  of  chest.     New  growth  in  left  lung 
extending  to  right  lung.     (One-tliird  life  size.) 


Diagnosis  of  New  Growth  made  by  Aid  of  X-Rays  confirmed  by 
Autopsy. — Jacob  D.,  twenty-five  years  old,  entered  the  Boston  City 
Hospital  August  3,   1898.     A  patient  of  Dr.  G.  G.  Sears. 

History.  —  Began  to  cough  two  days  before  entrance.  Soreness 
across  lower  chest.  Chest  enlarged  for  three  weeks.  Reclining  in  bed, 
especially  on  the  left  side,  caused  coughing.  Expectorated  whitish 
material.  Coughed  up  dark  blood  "a  long  time  ago."  Had  lost  consid- 
erable flesh. 


NEW   GROWTHS.     ENLARGED    GLANDS  339 

August  5.  Left  chest  aspirated,  and  thirty-eight  ounces  of  bloody- 
fluid  withdrawn. 

August  8.  It  was  noticed  that  the  whole  chest  pulsated,  and  when 
the  patient  was  aspirated  again  on  this  day  the  needle  seemed  firmly 
held  and  had  a  distinct  impulse  with  each  pulsation  of  the  heart. 

Dr.  Sears  kindly  allowed  me  to  examine  the  patient  with  the  X-rays, 
and  the  result  is  given  below  :  — 

X-ray  examination  with  the  screen,  made  on  August  10,  showed 
that  the  whole  of  the  left  chest  was  uniformly  dark,  and  that  a  part  of 
the  right  chest  was  also  dark  as  far  as  the  right  nipple.  (See  Fig.  194.) 
The  darkened  area  in  the  neighborhood  of  the  right  nipple  was  evi- 
dently not  a  displaced  heart ;  I  thought  it  was  probably  due  to  a  new 
growth.  The  reason  for  this  conclusion  was  as  follows  :  the  apex  beat 
of  the  heart  was  felt  in  the  fifth  interspace,  just  inside  the  nipple,  there- 
fore the  outline  seen  to  the  right  of  the  sternum  could  not  well  be  the 
border  of  the  heart.  The  age  of  the  patient,  the  presence  of  bloody 
fluid  in  the  chest,  the  failure  to  find  bacilli,  and  the  loss  in  flesh,  taken 
in  connection  with  the  X-ray  examination,  all  pointed  toward  a  new 
growth.  This  diagnosis  was  confirmed  by  finding  a  part  of  a  spindle- 
cell  sarcoma  in  a  small  amount  of  material  which  was  withdrawn  from 
the  chest  on  the  end  of  a  needle  August  15  ;  and  subsequently  by  the 
autopsy.  The  latter  showed  that  the  tumor  had  evidently  arisen  from 
the  mediastinal  lymph-glands ;  that  the  left  lung  was  studded  with  soft, 
projecting,  round  tumor  nodules;  and  that  similar  ones  were  also  pres- 
ent in  the  right  lung. 

Tumors  in  Chest ;  Results  obtained  by  X-Ray  Examination  and  Aus- 
cultation and  Percussion  compared.  — The  following  case  is  given  to  show 
the  advantage  of  comparing  the  results  obtained  by  auscultation  and 
percussion  with  those  obtamed  by  an  X-ray  examination: — - 

H.  Leo^  cites  the  case  of  a  boy  ten  years  old,  an  abstract  of  which 
is  as  follows  :  — 

In  June  the  right  leg  was  amputated  above  the  knee  on  account  of 
sarcoma.  Recovered.  In  July  he  had  a  dry  cough.  In  August  com- 
plained of  pain  in  the  left  side  and  back.  In  September  there  was 
sudden  difficulty  in  breathing,  high  degree  of  dyspnoea,  great  weakness, 
accentuated  heart  activity,  and  pain  in  the  chest.  These  symptoms 
continued,  and  on  October  7  the  patient  died. 

^"Nachweis  eines  Osteosarkoms  der  Lungen  durch  Roentgenstrahlem,"  Berlin.  Idin. 
Wochnschr.,  April  18,  1898,  349-350 


340     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

The  day  before  his  death  an  X-ray  examination  showed  a  diffuse 
shadow  over  the  left  side,  with  an  irregular  boundary  touching  the  heart 
shadow ;  a  small  bright  zone  outside  of  this  boundary ;  and  a  shadow 
on  the  right  side  which  was  much  darker  than  the  diffuse  shadow  on  the 
left  and  almost  corresponded  to  the  heart  in  darkness.  This  dark  oval 
shadow  showed  a  clearly  delined  boundary.  The  extent  of  the  shadows 
far  exceeded  the  extent  of  the  dulness  as  determined  by  the  physical 
examination.  Percussion  had  only  given  a  dulness  on  the  left  side, 
reaching  downward  from  the  spine  of  the  scapula  to  its  lower  point,  and 
forward  to  the  axillary  line,  and  still  forward  to  the  right,  from  the  clav- 
icle down  to  the  third  rib,  but  indicated  that  the  lungs  were  otherwise 
normal,  and  only  by  the  X-ray  examination  was  the  seat  of  the  trouble 
ascertained. 

A  post-mortem  examination  a  day  later  corroborated  the  X-ray  indi- 
cations. 

Tumors  in  Head.  -^  Although  this  section  is  devoted  to  the  thorax,  it 
may  be  said  here,  for  want  of  a  more  convenient  place,  that  tumors  in 
the  brain  with  our  present  apparatus  and  inexperience  must  necessarily 
offer  a  good  deal  of  difficulty  to  detection  by  the  rays.  One  case,^ 
however,  has  been  reported,  where  the  skull  was  remarkably  thin,  in 
which  the  size  and  position  of  the  tumor  was  recognized  during  life, 
and  the  observations  were  confirmed  at  the  post-mortem  examination. 

Differential  Diagnosis.  —  The  following  case  shows  how  the  aj^pear- 
ances  seen  on  the  fluorescent  screen  in  a  new  growth  on  the  one  hand, 
and  a  pleurisy  with  large  effusion  on  the  other,  may  differ  from  or 
resemble  each  other  :  — 

George  I).,  thirty-nine  years  old,  entered  the  hospital  March  23,  1899. 
In  the  service  of  Dr.  C.  F.  Withington. 

Diagnosis.  —  Pleurisy  with  effusion. 

March  24.  Patient  aspirated  and  70  ounces  of  blood-tinged  fluid 
withdrawn. 

MarcJi  26.  Flatness  from  two  inches  below  spine  of  scapula  on  right 
side. 

MarcJi  27.  Aspirated  again  and  44  ounces  of  bloody  fluid  withdrawn. 
Flatness  just  below  angle  of  scapula.  Rising  toward  spine  of  scapula 
there  was  a  dull  area  where  the  breathing  was  diminished. 

1 "  Cerebellar  Tumor  about  the  Size  of  a  Lemon  recognized  Clinically,  demonstrated  by 
the  X-Ray  and  proved  by  Autopsy,"  by  Archibald  Church,  M.D.,  American  Journal  Medical 
Sciences,  February,  1899,  page  125. 


NEW   GROWTHS.     ENLARGED   GLANDS  34 1 

MarcJi  30.     No  tubercle  bacilli  found. 

April  5,  1899.     Discharged  relieved. 

October  24,  1899.  Reentered  the  hospital  and  was  placed  in  my 
service.     Meanwhile  the  disease  had  evidently  progressed. 

Diagnosis.  —  New  growth. 

History.  —  Seven  weeks  before  entrance  had  sharp  pain  in  the  right 
chest,  worse  on  deep  inspiration  ;  slight  dyspnoea ;  no  cough,  chills,  or 
fever.  At  work  until  ten  days  previous  to  entrance.  Right  chest  had 
been  tapped  seven  times,  no  fluid  obtained.  Had  lost  eight  pounds  in 
four  months. 

PJiysical  Examination.  —  Heart :  right  border  indeterminable  on 
account  of  dulness  in  the  right  chest.  Left  border  12.5  centimetres  to 
left  of  median  line.  Apex  in  fifth  space  in  the  nipple  line.  No  mur- 
murs. Lungs  :  left  chest  moved  more  than  right  in  respiration.  Marked 
bulging  of  lower  right  chest,  as  low  as  costal  margin.  Dulness  on  right, 
beginning  at  third  rib  in  front  and  spine  of  scapula  behind,  and  increas- 
ing to  flatness  at  right  base.  Respiratory  sounds  diminished  over  this 
area.  Tactile  fremitus  diminished.  Fine  crackling  and  medium  moist 
rales  in  back,  over  dull  area.  Tactile  fremitus  increased  over  upper 
right  front.  Liver  :  bulging  in  hepatic  region.  Lower  border  3.5  fingers 
below  costal  margin  in  the  nipple  line. 

On  October  25  the  X-ray  examination  zvith  the  screen  slioived  that  the 
whole  of  the  right  chest  was  dark  throughout,  as  well  as  much  of  the 
upper  portion  of  the  left  chest.  The  only  outlines  visible  were  those  of 
the  left  diaphragm  and  a  portion  of  the  left  and  lower  border  of  the 
heart.  This  X-ray  examination  at  first  suggested  pleurisy  with  effusion, 
but  a  more  careful  consideration  of  the  appearances  on  the  screen  showed 
that  they  might  be  due  to  another  cause. 

Let  us  study  the  cut  (Fig.  195)  a  moment  and  see  how  the  X-ray  signs 
reproduced  there  should  be  interpreted.  The  darkened  right  side  sug- 
gests pleurisy  with  effusion,  and  the  shaded  left  apex  pulmonary  tuber- 
culosis ;  but,  given  a  large  pleuritic  effusion,  as  the  right  side  taken  by 
itself  indicates,  we  should  expect  to  find  the  heart  more  displaced  to  the 
left  than  is  the  case.  Further,  in  a  pleurisy  with  large  effusion  on  the 
right  side,  the  left  lung  and  pleura  being  normal,  the  diaphragm  on 
the  left  side  would  be  seen  lower  in  the  chest  than  in  health,  because  it 
would  have  been  pushed  down  by  the  organs  of  the  right  side  that  were 
displaced  to  the  left  by  fluid ;  whereas  in  this  respect  the  cut  shows  a 
normal  diaphragm  on  the  left  side.     If  this  cut  is  compared  with  the 


34 


2     THE    ROENTGEN    RAVS   IN    MEDICINE   AND   SURGERY 


diagram  of  pleurisy  with  effusion  (Fig.  128  in  the  chapter  on  Pleurisy), 
the  points  of  difference  in  the  two  illustrations  will  be  noted  and  the 
matter  will  be  made  clearer.  In  Fig.  128  we  see  the  ;;///<:/^-displaced 
heart  and  the  lowered  diaphragm  that  are  characteristic  of  pleurisy 
with  large  effusion  ;  but  these  signs  are  wanting  in  the  cut  we  are 
considering. 

Let  us  now  take  up  the  history  and  physical  signs.     Thoracentesis 
in  March,    1899,  had  shown  the  presence  of  some  bloody  fluid  in  the 


Qeorc^e  D 
Sarcoma  oF  jLi/no3 
OcJ'  2S&  less 


Fk;.  195.     George  D.     Cut  of  tracing  made  with  screen  on  front  of  chest.     New  growtli  in  right  hin£ 
and  at  apex  of  left  lung.     (Cut  one-third  life  size.) 


thorax,  but  when  the  chest  was  tapped  in  October,  no  fluid  was  with- 
drawn. The  physical  signs  indicated  to  a  large  extent  pleurisy  with 
much  effusion,  but  the  history  and  appearances  suggested  a  different 
explanation.  Therefore,  taking  the  X-ray  examination  in  connection 
with  these  two  latter  facts,  the  diagnosis  of  a  new  growth  seemed  the 
more  probable  one.  Of  course  the  diaphragm  might  be  lowered  on 
the  left  side  by  a  large  new  growth  in  the  right  chest  as  well  as  by  a 


NEW   GROWTHS.     ENLARGED    GLANDS  343 

large  quantity  of  liquid  there,  but  when  we  find  the  diaphragm  normal 
on  the  left  side  and  a  dark  area  on  the  right,  we  may  well  suspect  that 
this  appearance  in  the  lung  is  due  to  something  other  than  pleurisy 
with  large  effusion. 

On  October  31  I  asked  Dr.  John  C.  Munro  to  see  the  patient  in  con- 
sultation, and  the  next  day  he  was  transferred  to  the  surgical  side  of  the 
hospital.  On  November  3  Dr.  Munro  operated,  and  several  small  masses 
were  removed  for  examination.  The  pathological  diagnosis  was  spindle- 
cell  sarcoma.  On  November  8  he  operated  again  and  removed  as 
much  of  the  new  growth  as  seemed  wise.  On  November  27  another 
operation  was  done  at  the  request  of  the  patient,  which  he  bore  very 
well.  In  April,  1900,  the  patient  again  returned  to  the  surgical  side  of 
the  hospital,  and  it  was  evident  that  the  disease  had  progressed. 

X-Ray  Appearances  of  an  Extensive  New  Growth  and  an  Interstitial 
Fibrous  Pneumonia  compared. — The  comparison  of  the  cut  (Fig.  195, 
George  D.)  of  a  new  growth,  with  the  diagram  of  pleurisy  with  large 
effusion  (see  Fig.  128,  chapter  on  Pleurisy)  has  shown  us  how  the 
appearances  seen  on  the  screen  may  differ  in  these  two  diseases,  and, 
therefore,  how  the  X-rays  may  aid  us  in  making  a  differential  diagnosis 
when  used  in  connection  with  other  methods.  Now  let  us  compare  the 
cut  of  a  new  growth  (George  D.)  and  an  interstitial  fibrous  pneumonia 
(Fig.  196,  Richard  S.),  and  see  how  the  appearances  seen  on  the 
screen  in  these  two  diseases  resemble  each  other. 

Richard  S.,  forty-one  years  old,  entered  my  service  at  the  Boston 
City  Hospital  October  16,  1899. 

History.  —  Pneumonia  two  years  ago.  Rheumatism  in  muscles  of 
back  from  time  to  time  for  past  three  years.  Always  fairly  well  and 
strong  excepting  this.  For  past  one  and  one-half  years  had  had  dysp- 
noea on  exertion. 

Present  Ilhiess.  — Well  up  to  ten  days  ago,  when  taken  with  chills. 
Pain  throughout  back  and  chest.  Dyspnoea  with  cough.  Dyspnoea 
increased  in  severity  with  some  orthopnoea.  Has  vomited  every  day 
since  second  day  of  attack,  and  complains  of  sharp  pain  over  praecordia. 
Much  expectoration  with  cough,  whitish  and  frothy  in  character.  No 
rusty  sputa. 

PJiysical  Examination.  —  Lungs  :  percussion  note  over  right  front 
and  upper  right  back  slightly  higher-pitched  than  left ;  respiratory 
sounds  increased  on  right,  diminished  over  left.  Dulness  over  lower 
half  of  left  back,  with  bronchial  breathing  in  areas,  and  bronchophony, 


344 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


also  medium  and  fine  crackling  rales.  Tactile  fremitus  absent  in  left 
back.     Sibilant  and  sonorous  rales  throughout  upper  left  back. 

October  1 8.      No  tubercle  bacilli  found  in  sputa. 

October  30.  X-Ray  Exavii nation  zvith  Screen  (see  Fig.  196).  — 
Heart  is  found  not  displaced  to  right.  Left  chest  dark  throughout, 
but  rather  lighter  below  than  above.     Outline  of    left  diaphragm  not 


Rjcharcf3 
Jn/erst/fial  rjhwu6  Pneamonjo 
Odoher  3oA- 


Fig.  196.  Richard  S.  Cut  of  tracing  made  with  screen  on  front  of  chest.  Interstitial  fibrous 
pneumonia.  Left  chest  dark  throughout,  but  darker  in  upper  than  lower  part.  Ape.x  beat  felt  at  X. 
This  darkened  area  does  not  indicate  pleurisy  with  large  effusion,  as  the  heart  is  not  sufficiently  dis- 
placed ;  likewise  the  upper  part  of  the  chest  is  darker  than  the  lower,  which  would  not  be  the  case 
in  pleurisy  with  effusion.     (Cut  one-third  life  size.) 


seen.  Left  border  of  heart  barely  seen,  but  this  faint  outline  is  not 
given  in  the  cut.     Apex  beat  shown  in  the  cut  by  a  cross. 

Patient  died  November  25. 

The  autopsy  showed  that  the  left  pleural  cavity  was  obliterated  and 
the  whole  left  lung  was  dense.  Small  cavity  in  the  base  filled  with 
blood.  Diagnosis:  "Interstitial  fibrous  pneumonia.  Purulent  bron- 
chitis." 


NEW   GROWTHS.     ENLARGED    GLANDS 


545 


New  Growth  in  Chest  Wall.  —  The  following  case  shows  how  an 
X-ray  examination  may  be  used  to  indicate  that  a  new  growth  in  the 
chest  wall  does  not  extend  to  the  lung  :  — 

Martin  F.,  entered  the  hospital  July  7,  1898,  suffering  from  typhoid 
fever.     Patient  of  Dr.  E.  M.  Buckingham. 

There  was  a  circular  prominence  on  his  chest,  6  centimetres  in 
diameter,  lying  between  the  right  nipple  and  the  heart.    (See  Fig.  197-) 


Mar/Jn  r 
Crou//A  //>  CAe^t  /fa// 


Fig.  197.  Martin  F.  The  shaded  area  on  the  right  chest  represents  the  size  and  position  of  an 
indurated  mass  which  was  prominent  when  the  chest  was  inspected  and  cast  some  shadow  on  the 
screen.     The  outline  of  the  diaphragm  and  heart  are  X-ray  outlines.     (Cut  one-third  life  size.) 


It  was  important  to  know  whether  the  cause  of  this  prominence  was 
connected  in  any  way  with  the  thoracic  cavity. 

X-Rav  Examination  ivith  Screen.—  I  therefore  examined  the  patient 
with  the  X-rays,  first,  while  he  was  lying  on  his  back,  and  saw  a  dark- 
ened area  on  the  screen  corresponding  to  the  prominence  on  the  chest, 
but  found  that  the  new  growth  was  probably  limited  to  the  chest  wall, 
for  the  outlines  of  the  lungs,  the  movement  of  the  diaphragm,  and  the 
outline  of  the  right  border  of  the  heart  did  not  give  evidence  that  the 
new  growth  extended  inward.     I  then  examined  the  patient  lying  first 


346     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

on  one  side  and  then  on  the  other,  and  it  was  evident  in  these  posi- 
tions that  the  growth  did  not  extend  inward,  as  the  king  was  clear 
behind  it. 

The  cut  (see  Fig.  197,  Martin  F.)  given  differs  from  the  others  in  this 
chapter,  inasmuch  as  the  Hues  marking  the  new  growth  are  intended  to 
represent  what  was  seen  on  the  outside  of  the  chest,  and  not  the  shadow 
thrown  on  the  fluorescent  screen  ;  but  the  full  and  broken  black  lines 
are  the  lines  of  the  heart  and  diaphragm  seen  on  the  screen. 

The  patient  recovered  from  his  typhoid  fever  and  was  discharged. 

Echinococcus  of  the  Lung.  —  Levy-Dorn  and  Zadek  ^  state  that  ac- 
cording to  different  statistics,  from  seven  to  twelve  per  cent  of  all  the 
echinococci  appear  in  the  lungs,  most  frequently  in  the  lower  right  lobe, 
as  the  disease  is  often  of  secondary  origin  and  arises  from  the  liver. 
They  report  a  very  instructive  case,  the  abstract  of  which  is  as  fol- 
lows :  — 

The  patient  was  a  robust  man;  had  been  a  butcher.  In  1897  he 
had  dyspnoea,  hsemoptyses,  expectoration  of  pus  sometimes  streaked 
with  blood;  tubercle  bacilli  were  not  found.  In  November,  1898, 
echinococci  were  found  in  the  expectoration. 

The  signs  by  percussion  and  auscultation  were  not  decisive,  but 
an  X-ray  examination  showed  a  shadow  about  5  centimetres  long  and 
4  centimetres  broad,  with  a  light  interior  and  a  dark  edge.  This 
shadow  was  connected  with  the  diaphragm  by  a  short  streak.  The  dia- 
phragm was  pulled  up  at  the  junction  of  this  streak  or  band,  and  could 
not  contract  in  full  inspiration  as  well  as  on  the  left  side.  In  the  left 
lung  there  was  an  oval  black  shadow  about  the  size  of  a  plum.  These 
shadows  were  found  to  have  a  central  position. 

The  conclusions  from  the  X-ray  examination  were  as  follows :  The 
patient  had  two  separate  areas  of  echinococci,  one  in  the  right  and  one 
in  the  left  lung.  Their  central  position  explained  the  negative  result  of 
percussion.  As  the  middle  portion  of  the  area  in  the  right  lung  was 
light,  it  was  probable  that  the  echinococci  were  discharged  from  that 
side  and  that  the  cavity  had  become  filled  with  air,  but  were  still  present 
in  the  left  lung  as  indicated  by  the  dark  area. 

Malignant  Disease  of  the  Abdomen ;  Question  of  Extension  into 
Thorax. — The  X-ray  examination  may,  in  malignant  disease  of  the 
abdomen,  assist  in  determining  whether  or  not  the  disease  has  extended 
to  the  thoracic  cavity. 

1  Berlin,  klin.  IVochnschr,,  May  15,  1899,  p.  431. 


NEW   GROWTHS.     ENLARGED    GLANDS  347 

B.  B.,  a  patient  of  Dr.  Munro,  had  cancer  of  the  Hver,  and  the  physi- 
cal signs  suggested  a  possible  extension  of  the  disease  to  the  lungs. 

My  X-ray  cxaviination  zoit/i  the  screen,  however,  showed  that  the 
lungs  were  perfectly  clear.  The  physical  signs  which  indicated  exten- 
sion into  the  thorax  also  improved,  so  that  the  disease  probably  had  not 
reached  the  thoracic  cavity.  This  case  and  a  tracing  are  given  in 
Chapter  XIV,  page  376. 

A  Bunch  of  Enlarged  Glands  simulating  the  Outline  produced  by  an 
Aneurism  when  examined  from  One  Direction.  —  In  some  instances  new 
growths  under  the  upper  part  of  the  sternum  simulate  a  thoracic  aneu- 
rism. It  is  therefore  important  to  examine  the  dark  area  seen  on  the 
screen  during  both  inspiration  and  expiration,  and  carefully  observe  its 
outline.  If  there  is  no  pulsation  of  the  outline  seen,  the  shadow  may  or 
may  not  be  due  to  an  aneurism.  If  there  is  pulsation  and  the  outline 
increases  in  size,  the  dark  area  is  probably  caused  by  an  aneurism.  If 
there  is  pulsation  which  produces  displacement,  but  does  not  enlarge 
the  outUne,  the  dark  area  is  more  apt  to  be  a  new  growth  than  an 
aneurism. 

The  following  case  is  chosen  to  show  how  a  bunch  of  enlarged  glands 
may  give  outlines  on  the  iiuorescent  screen  that  simulate  those  produced 
by  an  aneurism  ;  also  to  show  the  importance  of  examining  the  chest 
from  different  directions  in  order  to  locate  exactly  the  object  producing 
the  shadow  cast  on  the  screen  ;  and,  third,  to  show  the  importance  of 
considering  other  indications  of  disease  besides  the  appearances  seen 
on  the  screen. 

Mr.  C,  forty  years  of  age,  was  referred  to  me  by  Dr.  John  W. 
Farlow  for  an  X-ray  examination.  He  had  complained  of  pressure 
which  was  sometimes  felt  in  the  upper  portion  of  the  thorax.  He  had 
paralysis  of  the  vocal  cord,  dyspnoea,  etc.  Some  of  these  symptoms 
suggested  an  aneurism,  but  other  signs  characteristic  of  the  disease 
were  wanting. 

X-Ray  Examination  with  Screen.  —  I  examined  the  patient  with  the 
fluorescent  screen,  and  found  that  there  was  a  dark  area  in  the  neigh- 
borhood of  the  aorta,  as  indicated  in  the  cut  (Fig.  198,  Mr.  C),  but  there 
was  no  pulsation  of  these  abnormal  outlines  ;  that  there  was  obstruction 
to  expiration  ;  that  the  lungs  were  dilated  to  their  fullest  extent ;  that 
the  diaphragm  was  low  down  in  the  chest,  nearly  as  far  as  the  costal 
border,  and  moved  very  little  in  expiration. 

Judging  by  the  appearances  on  the  screen,  it  was  difficult  to  decide 


34S     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

whether  we  had  to  do  with  an  aneurism  or  a  new  growth,  but  I  finally- 
inclined  to  the  former  view,  though  I  did  not  make  this  diagnosis ;  the 
case  was  puzzling,  and  the  outlines  seen  on  the  screen,  though  in  some 
respects  similar,  yet  differed  from  any  other  case  of  aneurism  of  the 
aorta  that  I  had  examined  with  the  X-rays.  I  expected,  however,  to  see 
the  patient  again,  get  history,  and  take  an  X-ray  photograph  ;  but  was 
disappointed  in  this  expectation.  Where  the  appearances  are  unusual 
at  least  two  radioscopic  examinations  should  be  made. 


o 


X^  Mr  C. 


Fig.  198.  Mr.  C.  Cut  of  tracing  made  with  screen  on  front  of  chest.  Patient  with  lymph- 
adenitis casting  a  shadow  beside  the  upper  part  of  the  sternum.  Lungs  much  distended,  diaphragm 
low  down,  and  but  little  movement  in  respiration.     Tracheal  obstruction.     (Cut  one-third  life  size.) 


The  patient  died  on  May  10,  1899,  and  no  aneurism  was  found. 
An  account  of  the  case  was  given  in  an  article  by  Dr.  Classen  which 
was  published  in  the  Albany  Medical  Annals,  and  I  quote  the  portion 
of  the  autopsy  record  relating  to  the  aorta.  The  autopsy  was  made  by 
Dr.  Lartigau  :  — 

"  Aorta.  —  Shows  no  apparent  dilatation  at  any  point.  The  circum- 
ference of  the  thoracic  aorta  is  5.5  centimetres;  the  circumference  of 


NEW    GROWTHS.     ENLARGED    GLANDS 


349 


the  abdominal  aorta  is  5  centimetres.  The  intima  is  markedly  irregu- 
lar, the  irregularity  being  due  to  various-sized  areas  of  elevated  fatty 
atheroma.  Behind  the  trachea,  at  a  point  on  a  level  with  the  aortic 
arch,  and  situated  more  to  the  left  of  the  median  line,  is  a  bunch  of 
enlarged  glands  about  the  size  of  a  small  orange.  The  individual 
glands  vary  in  size  from  a  pea  to  those  having  a  diameter  of  3  centi- 
metres. They  are  firm  in  consistency,  and  are  on  section  deeply  pig- 
mented in  the  central  portions,  less  so  in  the  peripheries,  which  are 
apparently  congested.  The  central  pigmented  portions  are  black. 
Now  and  then  on  the  sectional  gland  small  pin-point  to  pin-head  sized 
discrete  hemorrhages  are  apparent.  The  individual  glands  are  bound 
together  by  old  firm  bands  of  connective  tissue." 

In  this  patient  the  absence  of  pulsation  in  the  outlines  seen  on  the 
screen,  and  the  obstruction  to  expiration  on  both  sides,  were  opposed 
to  the  diagnosis  of  a  small  aneurism.  In  other  patients  I  have 
observed  this  incomplete  expiration  and  depressed  diaphragm  in  one 
or  in  both  lungs  where  there  was  obstruction  of  the  air  passage  of  one 
or  both  of  these  organs,  due  to  some  other  cause  than  an  aneurism. 
I  recall  one  case  in  which  there  was  obstruction  of  the  left  bronchus 
clue  to  a  well-marked  aneurism,  and  in  which  the  diaphragm  also  was 
depressed  and  had  little  movement. 

Enlarged  Bronchial  Glands  ;  Disease  extending  into  Lungs.  —  An 
X-ray  examination  may  be  of  value  in  the  early  stage  of  this  disease, 
when  no  other  method  will  serve  ;  and  successive  examinations  would 
enable  us  to  determine  whether  or  not  the  disease  is  progressing.  The 
following  case  indicates  that  we  may  get  signs  that  the  disease  originat- 
ing in  the  bronchial  glands  has  extended  into  the  lung  earlier  by  an 
X-ray  examination  than  by  other  methods  :  — 

Mrs.  S.,  thirty  years  old.  Patient  of  Dr.  John  C.  Munro.  Entered 
the  hospital  August  15,  1899. 

An  enlarged  gland  about  the  size  of  a  cherry,  just  posterior  to  the 
submaxillary  gland,  and  another  on  the  left  side  of  the  neck,  about  the 
level  of  the  sternocleidomastoid  muscle,  about  the  size  of  a  pigeon's 
egg,  were  removed  by  Dr.  Munro.  They  were  found  to  be  carcinoma- 
tous in  character.  On  September  18  she  reentered  the  hospital  with  a 
recurrence  beneath  the  submaxillary  scar,  and  a  new  enlargement  of 
glands  above  the  clavicle,  which  was  operated  upon  by  Dr.  Munro. 
On  November  6  he  removed  two  small  enlarged  glands  from  the  sub- 
clavian triangle  on  the  left  side  of  the  neck  ;  on  January  4,  1900,  he 


350 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


removed  several  small  enlarged  glands  from  the  superior  carotid 
triangle  and  from  the  subclavian  triangle  on  the  left  side  of  the  neck. 
The  patient  made  a  good  recovery  from  all  these  operations. 

On    March    9   the   patient    again    reentered    the    hospital    and  was 
examined  by  Dr.  Bowditch.      His  record  is  as  follows  :   "  Lack  of  per- 


MrsS 
CJajyec/  BroncJiia/  (^/and 


O 


Fig  199.  Mrs.  S.  Cut  of  tracing  made  with  screen  on  front  of  chest.  Carcinomatous  bronchial 
glands ;  extension  of  disease  into  left  lung,  suggested  by  darkened  area  over  and  outside  of  left 
nipple.     (Cut  one-third  life  size.) 


cussion  note  at  both  apices  ;  respiration  at  left  ape.x  in  front  broncho- 
vesicular  ;  no  rales  heard.  There  is  a  question  of  incipient  disease  at 
apices.     Sputum  examination  recommended." 

On  March  9  I  made  an  X-ray  examination  zvith  screen,  and  found  a 
darkened  area  on  the  left  side  of  the  chest  just  above  the  heart  and 
stretching  outward  toward  the  left.  The  portion  of  this  area  just  above 
the  heart  was  darker  than  its  outward  portion,  as  indicated  in  the  trac- 
ing.    (See  Fig.  199.) 

In  the  early  part  of  April  I  suggested  to  her  physician,  Dr.  Met- 
calf,  another  X-ray  examination,  but  she  was  already  too  weak  to  come 


ABSCESS  AND   GANGRENE   OF    LUNG 


i5i 


to  Boston.     She  died  in  the  following  June  from  her  pulmonary  trouble. 
There  was  no  autopsy. 

Abscess  and  Gangrene  of  Lung.  —  The  more  exact  location  of  an 
abscess  in  the  lung,  or  of  a  circumscribed  gangrenous  area,  than  has 
hitherto  always  been  possible,  will  doubtless  assist  the  surgeon  when 
he  operates  on  these  cases.  The  following  case  shows  that  we  may 
locate  the  exact  position  of  an  abscess  in  the  lungs  by  means  of  an 
X-ray  examination  :  — 


Mar II  C 


Q<7/)^/r/ur  -  /-^ifiMLuna 


® 


Fig.  200.     Mary  C.     Cut  of  tracing  made  with  screen  on  front  of  chest.      Gangrene  of  right  king. 
Excursion  of  diaphragm  shortened  on  right  side.     (Cut  one-third  hfe  size.) 


Mary  C,  twenty-four  years  old,  entered  the  hospital  April  13,  1898. 
Patient  of  Dr.  V.  Y.  Bowditch. 

Diagnosis.  —  Abscess  or  gangrene  of  lung. 

History.  —  Had  severe  pain  in  the  right  chest  for  three  weeks. 
For  two  weeks,  cough  and  expectoration,  large  in  quantity  and  very 
offensive ;  losing  flesh  and  strength  rapidly  ;  breath  very  foul. 

April  13.  Physical  Examination. —  Wtdirt's  area  normal;  slight 
systolic  murmur  over  pulmonary  area.  Lungs :  slight  dulness  at  the 
right  apex,  down  as  far  as  the  third  rib  in  front  and  the  spine  of 
scapula   behind;    slight    dulness  to  a   less  degree   in    the    left    apex; 


352     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

moist  crackling  rales  in  both  apices,  without  any  marked  change  in 
respiratory  murmur.  A  few  rales  heard  extending  down  right  back  as 
far  as  the  angle  of  the  scapula. 

April  15.  Patient  seen  in  consultation  with  Dr.  George  H.  Monks, 
who  advised  examination  by  X-rays,  and,  therefore,  I  examined  her  with 
the  fluorescent  screen  and  found  a  well-defined  dark  area  at  the  right 
apex,  and  that  the  excursion  of  the  diaphragm  was  shortened  on  that 
side  and  shortened  from  below.     (See  Fig.  200.) 

April  18.  Operation  done  by  Dr.  Monks,  who  opened  near  the 
right  apex  into  an  area  corresponding  to  the  dark  shadow  seen  in  Fig. 
200,  from  which  escaped  a  very  foul  odor  and  some  pus. 


CHAPTER    XIII 

CONCLUSION    OF    THORAX 

Broadly  speaking,  it  may  be  said  that  a  darkened  apex  naturally 
suggests  beginning  pulmonary  tuberculosis ;  a  darkened  area  in  the 
middle  of  the  lung,  pneumonia ;  and  a  darkened  area  in  the  lower  por- 
tion, a  pleurisy  with  effusion  or  an  empyema :  for  it  is  well  known  that 
the  first  two  areas  are  the  frequent  sites  of  tuberculosis  and  pneumonia, 
respectively,  and  the  fluids  present  in  pleurisy  and  empyema  naturally 
darken  the  lowest  part  of  the  chest.  There  are,  of  course,  many  excep- 
tions to  this,  as  when  a  patient  is  convalescing  from  pneumonia  at  the 
apex  there  may  be  appearances  which  would  simulate  those  found  in 
early  tuberculosis,  namely,  a  darkened  apex  and  a  shortened  excursion 
of  the  diaphragm ;  but  the  history  of  a  recent  pneumonia,  and  a  second 
examination  after  an  interval  of  a  week  or  so,  showing  an  improvement 
in  these  signs,  would  point  out  their  probable  cause.  If  it  is  a  ques- 
tion whether  the  lung  is  involved,  or  whether  there  is  fluid  in  the  pleural 
sac,  it  should  be  borne  in  mind  that  in  the  latter  case  there  is  more  apt 
to  be  a  change  in  the  position  of  the  neighboring  organs,  which  is  seen 
on  the  screen,  and  also  that  the  appearances  on  the  screen  are  more 
hkely  to  vary  when  the  patient  is  examined  in  different  positions.  The 
X-rays  assist  the  practitioner  to  recognize  an  encapsulated  and  an 
interlobar  fluid  ;  to  differentiate  an  empyema  from  a  multiple  abscess  of 
the  liver.  Atelectasis  and  syphihs  produce  conditions  in  the  lungs  that 
may  be  observed  on  the  fluorescent  screen. 

An  abnormal  condition  of  the  heart  may  be  recognized  by  its  out- 
lines, its  size,  by  its  displacement,  by  watching  the  character  of  its  move- 
ments during  the  respiratory  tests,  and  also  by  observing  the  change  in 
outline  of  this  organ  produced  by  the  pulsations  during  systole  and  dias- 
tole. The  X-rays  assist  the  practitioner  to  differentiate  between  an 
enlarged  heart  and  a  pericardial  effusion,  and  between  a  pericardial  effu- 
sion and  an  encapsulated  empyema,  and  to  recognize  adhesions  which 
2  A  353 


354     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

limit  the  change  in  the  position  of   the  heart  between  expiration  and 
deep  inspiration. 

An  aneurism  is  suggested  if  a  darkened  area  is  seen  in  either  side 
of  the  sternum  above  the  heart.  The  changes  seen  taking  place  in  the 
thorax  as  a  new  growth  increases,  by  means  of  X-ray  examinations  made 
at  intervals,  are  suggestive.  A  new  growth  may  simulate  for  a  time 
other  abnormal  conditions. 

Acute  and  Chronic  Processes  compared.  —  In  general,  I  may  say  that 
the  appearances  seen  on  the  screen  in  acute  processes  would  vary  after 
an  interval  of  a  "week  or  so,  whereas  those  due  to  chronic  conditions 
would  not  so  vary  in  this  length  of  time.  Hence  the  practical  impor- 
tance of  two  examinations,  for  this  reason  as  well  as  for  others. 

Association  of  an  Acute  and  Chronic  Process.  —  An  acute  and  chronic 
process  may  obtain  in  the  thorax  at  the  same  time  ;  for  example,  a 
pleurisy  with  effusion  may  be  associated  with  a  tuberculosis  of  the  lung 
on  the  same  or  on  different  sides  of  the  chest,  or  a  patient  may  be 
suffering  from  a  pneumonia  in  one  lung  and  a  tubercular  process  in  the 
other ;  in  this  case  improvement  would  be  seen  on  the  screen  in  one 
lung,  while  the  signs  in  the  other  lung  would  remain  stationary  or 
increase ;  or  emphysema  and  tuberculosis  may  occur  together. 

Association  of  Two  Acute  Diseases. — Two  acute  diseases  may  be 
found  in  the  same  patient  at  the  same  time,  for  example,  empyema  and 
pneumonia. 

It  is  obvious  that  more  experience  is  required  to  interpret  the 
appearances  seen  on  the  screen,  if  more  than  one  disease  is  present ; 
or  if  it  is  a  question  whether  or  not  certain  of  the  signs  seen  are  the 
results  of  a  disease  which  occurred  some  years  previously, —  an  old  and 
quiescent  tuberculosis,  or  adhesions  from  a  former  pleurisy  with  or 
without  a  pneumonia,  for  example. 

X-Ray  Examination  of  the  Whole  Chest,  not  of  One  Organ  Alone.  —  It  j 
is  likewise  evident  that,  in  making  an  examination  of  the  thorax,  the  i 
condition  of  one  organ  must  not  be  studied  alone,  but  in  connection  with  ■ 
the  other  outlines  in  the  chest.  That  is  to  say,  the  position  of  the  heart,  , 
for  instance,  should  be  noted  in  connection  with  the  appearances  in  the  ; 
lungs,  and  those  in  the  lungs  with  the  heart.  If,  for  example,  we  find  |J 
that  during  full  inspiration  the  heart  is  drawn  toward  the  side  of  the  r 
chest,  any  suspicions  that  have  been  aroused  concerning  the  lung  may  i 
be  strengthened.  On  the  other  hand,  if  both  lungs  are  darkened  at 
their  bases  in  valvular  disease,  it  is  a  sign  of  failure  in  compensation ; 


CONCLUSION    OF   THORAX  355 

or,  if  in  renal  disease,  it  is  a  sign  of  serious  import.  Without  citing 
further  examples,  I  think  it  is  clear  that  the  practitioner  must  not  only 
consider  the  appearances  observed  by  the  X-rays  in  connection  with 
other  signs  and  symptoms,  but  that  he  must  also  consider  the  X-ray 
examination  of  one  organ  in  connection  with  that  of  another. 

X-Ray  Examinations  made  by  Trained  Physicians,  preferably  Special- 
ists of  Thoracic  Diseases.  —  The  conclusion  naturally  follows  that  the 
medical  use  of  the  X-rays  must  be  in  the  hands  of  trained  physicians, 
and  that  they  must  learn  to  make  and  interpret  these  examinations,  just 
as  they  have  learned  the  use  of  other  methods  of  examination,  as,  for 
instance,  auscultation  and  percussion.  This  statement  may  be  still 
further  limited  by  adding  that  this  method  of  examining  the  chest  is 
one  which  should  be  used  chiefly  by  those  who  make  a  specialty  of 
thoracic  diseases,  just  as  the  ophthalmoscope  is  most  valuable  to  those 
who  are  specialists  in  diseases  of  the  eye.  Nevertheless,  all  medical 
schools  should  teach  the  method  of  X-ray  examination  in  connection 
with  auscultation  and  percussion,  even  though  the  student  should  never 
have  the  opportunity  to  use  this  new  method  himself  when  he  becomes 
a  practitioner ;  for  the  use  of  these  examinations  will  teach  the  student 
to  interpret  better  the  signs  given  by  the  former  methods  and  to  under- 
stand their  Hmitations.  It  has  been  said  that  the  "X-rays  are  a  most 
effective  method  of  showing  how  great  a  role  the  imagination  may  play 
when  using  auscultation  and  percussion." 

X-Ray  Examination  Part  of  Physical  Examination.  — An  X-ray  appa- 
ratus intelligently  used  gives  the  physician  the  not  infrequent  satisfaction 
of  making  a  definite  diagnosis  when  it  would  not  otherwise  be  done,  or  of 
basing  his  opinion  and  advice  on  clearer  perceptions  of  the  conditions 
present  than  would  otherwise  be  possible.  In  some  cases  it  may  or 
may  not  add  anything  to  the  information  obtained  by  other  methods  ; 
but  the  ability  to  make  the  usual  physical  examination  of  the  chest,  and 
then  look  at  the  problem,  by  means  of  an  X-ray  examination,  from 
another  standpoint,  and  thus  consider  the  question  anew,  and  by  its 
means  confirm  or  disprove  the  first  opinion,  is  a  gain  that  will  not  be 
questioned  by  any  physician  who  is  familiar  with  diseases  of  the  chest, 
and  has  informed  himself  in  the  use  of  the  X-rays.  The  ordinary  phys- 
ical examination  is  not  complete  without  an  X-ray  examination.  The 
latter  should  be  used  as  a  part  of  the  former. 

Need  of  X-Ray  Apparatus  by  Physicians.  —  I  am  not  infrequently 
asked  by  physicians  whether  or  not  it  would  be  wise  for  them  to  pur- 


356     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

chase  an  X-ray  outfit.  The  foregoing  pages  will  enable  any  one  who 
reads  them  to  answer  this  question  for  himself.  It  is  evident  that  time 
is  required  for  the  practitioner  to  train  himself  in  the  use  of  the  appa- 
ratus and  in  making  examinations  of  the  chest.  There  are  also  pitfalls 
into  which  those  inexperienced  in  this  method  may  fall ;  for  example,  a 
physician  inexperienced  in  X-ray  examinations  may  tell  his  patient, 
on  the  evidence  thus  obtained,  that  he  has  some  serious  or  fatal  disease 
of  the  chest  which  does  not  exist,  when  a  physician  who  thoroughly 
understood  the  method  could  assure  the  patient  that  the  supposed  con- 
dition was  not  present.  These  mistakes  should  not  condemn  the  use  of 
the  X-rays,  but  rather  indicate  the  importance  of  carefully  observing 
and  interpreting  the  appearances  seen. 

The  study  of  X-ray  examinations  in  diseases  of  the  chest  has  been 
pursued  by  many ;  among  those  who  have  contributed  to  its  advance- 
ment, the  names  of  Bouchard,  Beclere,  Benedikt,  Grunmach,  Ziemssen 
and  Rieder,  and  Weinberger  are  especially  noteworthy. 


CHAPTER    XIV 

X-RAY    EXAMINATION    OF   THE   CESOPHAGUS,    ABDOMEN,    AND    PELVIS 

QLSOPHAGUS 

X-RAY  examinations  of  the  alimentary  canal  have  presented  greater 
difficulties  than  those  of  other  parts  of  the  body,  because  in  its  natural 
state  it  is  not  easily  distinguished  from  the  other  soft  parts  surrounding 
it ;  but  the  size  and  position  of  portions  of  it  may  be  determined  by 
artificial  means. 

(Esophagus.  —  A  metallic  sound  may  be  passed  through  the  oesopha- 
gus and  thus  its  outline  may  be  made  visible  on  the  fluorescent  screen  ; 
or  a  soft  rubber  tube  closed  at  its  inner  end  may  be  passed  into  the 
oesophagus  and  then  filled,  more  or  less,  as  desired,  with  mercur\-  or 
lead  shot.  The  dark  shadow  cast  by  the  metal  enables  the  physician  to 
determine  the  position  of  the  oesophagus. 

Stricture  of  the  CEsophagus.  —  A  stricture  probably  could  not  be 
recognized  by  the  X-rays  unaided,  but  if  a  rubber  tube  filled  with  shot 
or  mercury  were  inserted,  as  described  above,  and  the  point  watched  on 
the  screen  to  which  the  metal  descended,  the  rays  would  show  the  posi- 
tion of  the  stricture.  Also,  an  X-ray  examination  might  enable  the 
practitioner  to  distinguish  between  an  obstruction  due  to  stricture  or  to 
pressure  from  outside,  for  in  the  latter  case  the  oesophagus  might  be 
displaced.  If  this  displacement  were  caused  by  a  new  growth,  its  recog- 
nition might  lead  to  the  recognition  of  the  latter  by  directing  attention 
to  this  part  of  the  radiograph  and  negative.  (The  negative  should  be 
carefully  studied,  as  stated  in  Chapter  III,  page  96.) 

Diverticulum.  —  A  diverticulum  may  be  recognized  if  its  position 
is  a  favorable  one,  by  means  of  the  following  method.  Bismuth  is 
mixed  with  the  food,  and  when  the  patient  has  eaten  the  mixture  his 
throat  is  watched  on  the  screen.  If  the  bismuth  lodges  in  the  divertic- 
ulum, the  position  of  the  latter  mav  be  pointed  out  in  some  instances. 
Or  a  rubber  tube  filled  with   shot  or  mercury  may  be  inserted.      If  the 

357 


358   thf:  rokntgen  rays  in  medicine  and  surgery 

sound  finds  the  opening,  the  position  of  the  diverticulum  may  be  seen 

on  the  screen. 

Abdomen 

The  advances  in  certainty  and  ease  of  diagnosis  to  which  we  are 
assisted  by  the  X-rays  in  diseases  of  the  thorax  are  very  obvious,  but 
their  use  in  studying  diseases  in  the  abdominal  cavity  has  not  pro- 
gressed so  far  because  of  the  natural  difficulties  which  beset  the  prac- 
titioner when  making  observations  by  means  of  the  X-rays  in  this 
region  ;  but  I  think  sufficient  has  been  done  to  show  they  can  be  of 
assistance  to  us,  and  that  their  aid  in  this  field  is  capable  of  further 
development. 

In  the  thoracic  cavity  we  distinguish  the  outlines  of  the  heart  by 
their  contrast  with  the  lighter  lungs,  but  in  the  abdominal  cavity,  under 
ordinary  conditions,  such  contrast  does  not  prevail ;  it  may  be  produced, 
however,  bv  artificial  means. 

Introduction  of  Air  or  Gas  into  Organs.  —  First,  air  or  gas  may  be 
introduced  into  the  hollow  organs,  and  thus  their  position  may  be  made 
clearer  than  before  by  the  presence  of  the  light  areas  thus  produced  on 
the  screen.  For  instance,  air  may  be  pumped  into  the  large  bowel,  and 
the  outline  of  the  sigmoid  flexure  and  the  descending  colon  may  be 
easily  followed.  Not  only  does  this  procedure  enable  the  practitioner 
to  follow  the  position  occupied  by  this  portion  of  the  large  intestine, 
but  he  can  thus  more  readily  detect  abnormal  conditions  in  neighbor- 
ing parts  of  the  abdominal  cavity  ;  for  example,  some  pathological 
conditions  in  or  about  the  left  kidney  ;  or  if  the  stomach,  instead  of 
the  bowel,  has  been  distended,  some  conditions  about  the  pancreas, 
an  organ  which  has  been  quite  inaccessible  to  methods  of  physical 
examination. 

Introduction  of  Air  or  Gas  to  displace  Organs.  —  Second,  air  or  gas 
may  be  used  to  displace  the  parts  near  the  special  organ  we  wish  to 
examine  ;  for  example,  the  outline  of  the  spleen  may  be  followed  more 
fully  by  filling  the  stomach  and  lower  bowel  with  air  or  some  gas;  by 
this  means  the  lower  portion  of  the  spleen  is  surrounded  by  a  medium 
through  which  the  X-rays  pass  easily,  and  light  areas  are  brought  near 
the  denser  spleen,  and  contrast  is  thus  produced.  Gas  is  also  under 
certain  conditions  present  naturally  in  the  intestines,  and  under  these 
circumstances,  of  course,  contrast  obtains. 

Use  of  Bismuth.  —  Some  substance,  such  as  bismuth,  opaque  to  the 
rays,  may  be  introduced  into  the  hollow  organs. 


CESOPHAGUS,    ABDOMEN,   AND    PELVIS  359 

Let  us  now  consider  the  various  organs  of  the  abdomen  separately, 
beginning  with  the  stomach. 

Stomach 

Methods  for  observing  the  Stomach.  —  Various  methods  have  been 
devised  to  determine  the  size,  shape,  and  position  of  the  stomach  by 
means  of  the  X-rays.  First,  a  rubber  tube  provided  with  spiral  wire  ^ 
may  be  inserted  into  the  stomach,  —  Lindermann  determined  the  posi- 
tion of  a  stomach  by  this  means.  This  flexible  sound  adapts  itself  to 
the  wall  of  this  organ  and  its  outline  may  be  followed  on  the  screen. 
Second,  gas  may  be  pumped  into  the  stomach,  or  the  patient  may  be 
given  a  Seidlitz  powder,  each  of  the  two  powders  being  mixed  with  a 
tumbler  of  water  and  taken  separately.  The  dense  organs  surrounding 
the  stomach  are  thus  somewhat  displaced,  and  the  area  of  the  latter 
organ  appears  light  on  the  screen,  as  the  rays  pass  readily  through 
the  space  occupied  by  the  gas.  This  method  would  answer  to  deter- 
mine the  size  of  the  stomach  in  a  general  way,  but  would  not,  I  think, 
be  as  accurate  as  the  method  about  to  be  described.  Third,  some 
substance  opaque  to  the  X-rays,  such  as  an  emulsion  of  subnitrate  or 
metallic  bismuth,  may  be  poured  into  the  stomach  through  a  stomach 
tube  ;  or  powdered  subnitrate  or  metallic  bismuth  may  be  mixed  with 
the  food  —  the  latter  is  more  opaque  to  the  rays  than  the  former  — 
and  the  size,  shape,  and  position  of  this  organ  watched  on  the  screen. 
I  have  not  tried  all  of  the  various  methods  alluded  to,  but  have  found 
the  one  which  I  have  used,  namely,  the  mixture  of  subnitrate  of  bismuth 
with  food,  quite  satisfactory.  My  first  observations  were  made  four  years 
ago  with  this  salt,  the  use  of  which  would  naturally  suggest  itself  to  any 
one  who  was  seeking  a  substance  opaque  to  the  rays  and  harmless  to 
the  patient.  If  the  practitioner  does  not  wish  the  bismuth  to  pass  on 
into  the  intestines,  the  stomach  may  be  freed  from  "it  by  means  of  the 
stomach  tube  after  the  observations  on  the  stomach  have  been  made. 
Subnitrate  of  bismuth  has  been  used  in  making  these  examinations,  and, 
so  far  as  I  am  aware,  no  untoward  results  have  been  caused  by  its  use ; 
it  is  non-irritating  and  non-poisonous,  and  a  large  or  small  percentage 
of  it  may  be  used,  as  desired  ;  a  preparation  must  be  employed  that  is 
free  from  any  trace  of  arsenic  and  that  is  perfectly  pure. 

It  is  an  advantage  in  examining  the  stomach,  or  any  other  of  the 
organs  below  the  diaphragm,  to  have  the  bowels  empty ;  therefore 
certain  preparations  for  an  examination  of  the  stomach  are  necessary. 

1  Lindermann,  D''ntsclu  Med.   IVochnschr.,  1897,  ^^-  ^7>  P-  266. 


360     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

First,  a  good  movement  of  the  patient's  bowels  should  be  secured 
on  the  day  before,  and  on  the  morning  on  which  the  observations  are 
to  be  made,  in  order  to  diminish  the  obstruction  to  the  rays  and  allow 
the  bismuth  to  be  seen  as  clearly  as  possible. 

Second,  the  stomach  should  be  free  from  food. 

Third,  an  ounce  of  subnitrate  of  bismuth,  well  mixed  with  food, 
such  as  bread  and  milk,  should  be  given  to  the  patient  when  everything 
is  ready  for  the  examination.  The  food  should  be  stirred  from  time 
to  time  while  the  meal  is  being  taken,  or  perhaps  better,  some  of  the 
bismuth  which  has  settled  in  the  bottom  of  the  bowl  may  be  dipped  up 
with  each  spoonful. 

The  further  procedure  may  be  noted  in  the  description  given  of  the 
cases  observed. 

Two  or  three  years  ago  Dr.  W.  B.  Cannon,  then  a  student  of  the  Har- 
vard Medical  School,  who  had  made  some  excellent  observations  on  the 
digestion  of  cats,^  assisted  me  in  some  observations  on  the  stomachs  of 
two  children,  the  elder  of  whom,  James  W.,  was  ten,  and  the  younger, 
M.  W.,  was  seven  years  of  age.  As  a  rule  the  children  were  lying  on 
their  backs  on  the  canvas  stretcher  already  described ;  the  target  of  the 
vacuum  tube  was  45  to  60  centimetres  from  the  under  surface  of  the 
body  at  a  point  under  the  vmibilicus  ;  and  the  fluorescent  screen  was 
placed  over  the  abdomen.  The  outlines  observed  were  traced  by  one 
or  other  of  the  methods  already  detailed,  that  is  to  say,  either  on  the 
thin  sheet  of  glass  or  celluloid  which  covered  the  screen,  by  means  of 
a  lithographer's  pencil,  or  directly  on  the  skin  by  means  of  a  clinical 
pencil,  and  then  copied  on  to  tracing  cloth  for  permanent  record. 
After  the  first  tracings  were  made  the  glass  or  celluloid  was  washed 
and  used  again,  or  the  skin  was  washed  with  alcohol  and  thus  made 
ready  for  another  tracing,  according  to  the  method  adopted. 

The  results  of  our  observations  fall  naturally  into  three  divisions : 
first,  the  position  of  the  stomach  and  the  difference  of  position  obtaining 
between  the  standing  and  the  prone  positions  ;  second,  the  movements 
of  the  stomach  in  respiration  ;  and  third,  the  changes  in  the  shape  of 
the  stomach  during  digestion. 

Position  of  Stomach  when  standing  and  lying  down.  —  Saturday, 
September  23,  1899,  James  VV.,  ten  years  of  age,  was  examined  with 
the  X-rays  during  digestion.     He   finished  eating  a  pint  of   milk   into 

1  "  The  Movements  of  the  Stomach  studied  by  Means  of  the  Roentgen  Rays,"  American 
Journal  of  Physiology,  Vol.  I,  May  i,  1898. 


CESOPHAGUS,   ABDOMEN,   AND    PELVIS 


361 


which  bread  had  been  broken  and  with  which  nearly  an  ounce  of  sub- 
nitrate  of  bismuth  had  been  mixed  at  2.56  p.m.  The  tube  in  this  case 
was  53  centimetres  from  the  boy's  back.  A  coin,  which  cast  a  shadow 
on  the  screen,  was  placed  over  the  umbilicus  to  mark  the  position  of  the 
latter.     At  3.30  p.m.,  the  lower  border  of  the  stomach  was  on   a  line 


Fii;.  201.  (Jul  of  tracing  made  by  nicaiib  of  the  fluorescent  screen  from  a  girl  seven  years  old, 
showing  the  outUne  of  the  stomach  one  hour  after  a  meal  of  bread  and  milk  containing  subnilrate 
of  bismuth.  The  full  horizontal  line  is  at  the  level  of  the  iliac  crests ;  the  full  lines  at  right  angles  to  it 
are  the  outlines  of  the  body;  the  other  full  lines  indicate  the  position  of  portions  of  the  diaphragm, 
heart,  and  stomach  during  full  inspiration.  Broken  lines  show  position  in  expiration.  (Cut  one- 
half  its  original  size.) 

This  cut  I  published  in  the  Transactions  of  the  American  Climatological  Association,  1898. 


with  the  umbilicus;  at  5  p.m.,  1.5  centimetres  above  this  point.     During 
this  time  the  boy  was  lying  on  his  back. 

He  was  then  examined,  at  the  latter  hour,  when  standing,  and  in  this 
position  the  lower  border  of  the  stomach  was  1.5  centimetres  belovv  the 
umbilicus ;  that  is  to  say,  with  the  change  of  position  in  the  boy,  there 


-^62     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

was  a  difference  of  3  centimetres  in  the  position  of  the  lower  border  of 
the  stomach. 

Movement  of  the  Stomach  during  Respiration.  —  The  preceding  trac- 
ing shows  the  outline  of  the  stomach  of  M.  VV.,  a  girl  seven  years  old, 
during  inspiration  and  expiration,  one  hour  after  a  meal  of  bread  and 
milk  mixed  with  |-  ounce  of  subnitrate  of  bismuth  had  been  taken.  The 
full  horizontal  line  at  the  bottom  of  the  cut  is  on  a  level  with  the  iliac 
crests ;  the  other  full  lines  at  right  angles  to  it  are  the  outlines  of  the 
body  ;  the  full  lines  give  the  position  of  the  stomach,  heart,  and  dia- 
phragm in  full  inspiration  ;  and  the  broken  lines  show  their  position  in 
expiration.     The  tracing  is  one-half  the  original  size. 

The  four  following  tracings  are  taken  from  James  W.,  and  show  the 
size  and  position  of  the  stomach  during  the  process  of  digestion  ;  that 
is,  at  3.30,  4.20,  about  7.40  and  9.05  p.m.     The  patient  when  all  these  trac- 


I.W.     3^" 
'/3  Sly. 


Fig.  202.     James  \V.    Cut  of  X-ray  tracing.     3.30  P.M.     In  order  to  show  the  position  of  the  nipples, 
the  costal  borders,  and  the  iliac  crests,  this  tracing  was  reduced  to  one-third  its  original  size. 


CESOPHAGUS,    ABDOMEN,   AND    PELVIS 


3^3 


ings  were  made  was  lying  on  his  back  on  the  stretcher.  In  the  last 
three  tracings  the  broken  line  shows  the  position  of  the  stomach  in 
expiration  and  the  full  line  in  deep  inspiration. 


Fig.  203.      James  W.     Cut  of  X-ray  tracing.      4.20  P.M.     Broken   line  shows  size  and  position   of 
stomach  in  e.xpiration ;  full  line,  in  deep  inspiration. 


•64     THE    ROENTGEN    RAVS   IN    MEDICINE   AND    SURCiERV 


l.W. 
^1  ^'^y 


Fli;.  204.  James  \V.  Cut  of  X-ray  trac- 
ing made  on  celluloid.  7.40  P.M.  Broken 
line  shows  size  and  position  of  stomach  in 
expiration  ;  full  line,  in  deep  inspiration. 


l.W.  <^^^ 


/^si^t. 


I 


V\(',.  205.  James  W.  Cut  of  X-ray  tracing. 
9.05  I'.M.  Broken  line  shows  size  and  position  of 
stomach  in  e.xpiration  ;  full  line,  in  deep  inspiration.       | 


Changes  in  Shape  of  Stomach  during  Digestion.  —  This  point  i.s  illus- 
trated by  the  following  tr;icing"s  from  M.  W.,  taken  at  intervals  during  a 
period  of  4.]  hours.  The  child  finished  her  meal  of  bread  and  milk  at 
12  noon.  In  the  first  four  tracings  the  pyloric  region  is  represented  by 
a  dotted  line  because  that  portion  of  the  stomach  could  not  be  seen  dis- 
tinctly. The  change  in  size  and  shape  of  the  stomach  as  digestion  pro- 
gressed are  indicated  in  the  tracings  given  below.  It  will  be  seen  that 
the  upper  border  of  the  stomach  did  not  alter  so  much  in  position  as  did 
the  lower  border. 

A  third  child,  K.  A.,  five  years  of  age,  was  recovering  from  t}phoid 
fever  when  I   e.xamined  his  stomach  with  the  X-ravs.     The  procedure 


(ESOPHAGUS,   ABDOMEN,   AND    PELVIS 


365 


Fic.  206.  M.  W.  In  this  and  the  following  six  tracings,  which  are  full  size,  the  horizontal  line 
It  the  bottom  of  the  cuts  represents  the  position  of  a  metal  rod  which  was  placed  on  the  abdomen  on 
I  level  with  the  superior  iliac  crests. 

Where  two  tracings  are  given  in  one  cut,  they  are  intended  to  indicate  the  alternating  posi- 
ions  of  the  outline. 

The  vacuum  tube  was  under  the  X  indicated  in  this  first  tracing,  made  at  i  r.M. 


;66     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


was  as  follows  :   He  was  given  2  drachms  of  castor  oil  on   one  day,  in 
order  to  empty  the  bowels,  and  the  bowels  moved  that  day  and  again  the 


V 


Fig.  207.    M.  W.     Full  size. 


next  morning.  At  1 1  a.m.  on  the  latter  day  he  ate  a  bowl  of  bread  and 
milk  mixed  with  6  drachms  of  subnitrate  of  bismuth.  He  was  then 
examined  by  means  of  the  fluorescent  screen,  and  photographs  were 


CESOPHAGUS,   ABDOMEN,   AND    PELVIS 


J67 


taken  at  intervals  of  one  or  two  hours  for  several  hours  after  the  meal, 
the  plate  bemg  placed  on  the  front  of  the  body.    The  radiograph,  taken 


Fig.  208.    i\I.  W.    Full  size. 


3|  hours  after  the  meal,  showed  that  the  area  of  the  stomach  was  dark 
and  its  outline  was  best  defined  at  its  greater  curvature,  but  this  out- 
line was  still  better  defined  on  the  fluorescent  screen  because  the  stomach 


358     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

moves  during  respiration  and  therefore  its  outlines  are  blurred  on  the 
radiograph.  The  vertebrae  which  were  directly  behind  the  stomach 
could  not  be  seen.     The  area  to  the  left  of  the  stomach  was  free  from 


Fig.  2CD9.     M.  W.     Full  size. 

oismuth  and  showed  as  a  light  place  on  the  radiograph.  A  coin  was 
placed  directly  over  the  umbilicus  as  a  point  of  reference,  and  its 
shadow  could  be  seen  in  the  radiograph. 


CESOPHAGUS,   ABDOMEN,   AND    PELVIS  369 

The  next  radiograph  showed  that  the  bismuth  had  been  widely  dis- 
tributed through  the  abdominal  cavity,  and  that  it  had  gone  down  into 
the  pelvis  to  some  extent.    The  image  of  the  coin  was  almost  obscured. 


Fig.  210.     M.  W.    Full  size. 


The  last  radiograph,  made  S^  hours  after  the  meal,  showed  that  there 
was  .no  food  in  the  stomach,  and  that  the  great  mass  of  it  was   on  the 


370     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

left  side,  low  down,  and  had  reached  the  region  of  the  left  iliac  fossa. 
The  parts  which  had  been  dark  were  now  nearly  as  clearly  defined  as 
normal,  notably  the  vertebrae  behind  the  stomach.  The  next  morning 
the  dejections  had  the  color  characteristic  of  bismuth. 


Fig.  211.     M.  W.     Full  size. 


This  experiment  suggested  that  the  food  is  passed  through  the 
intestines  at  a  somewhat  rapid  rate ;  that  the  contents  of  the  alimentary 
canal  pause  in  the  stomach  and  in  the  large  intestine,  but  that  elsewhere 


CESOPHAGUS,   ABDOMEN,   AND    PELVIS 


171 


there  is  continuous  movement.  It  is  possible  that  there  was  a  trace  of 
castor  oil  left  in  the  system,  which  quickened  the  passage  of  the  food, 
or  the  fact  that  the  bowels  had  been  recently  emptied  might  have  made 
it  move  more  rapidly  than  it  would  have  done  under  normal  conditions ; 


r  10 


Fig.  212.     M.  W.     Full  size. 


or  still  other  factors  may  have  contributed  to  its  quick  movement.  The 
experiment  indicates  that  the  X-rays  afford  an  excellent  means  for  study- 
ing some  points  relating  to  the  physiology  of  digestion. 

Thus  we  see  that  if  bismuth  is  given  as  described  above,  an  outline 


372      IHE    R()ENTe;EN    RAVS    IN    MEDICINE   AND   SURGERY 

of  part  of  the  stomach,  its  position  in  inspiration  and  expiration,  and 
some  pecuUarities  of  shape  may  be  noted ;  likewise  that  its  changes  in 
size  during  the  process  of  digestion  may  be  observed ;  further,  the 
respective  rapidity  with  which  digestion  proceeds  in  different  individuals 
may  be  watched.  After  the  various  characteristics  belonging  to  the 
stomach  in  health  have  been  established,  the  presence  of  abnormal  con- 
ditions of  this  organ,  such  as  some  cases  of  malignant  disease,  will 
perhaps  be  more  readily  recognized  than  at  present.  The  constant 
presence  of  a  darkened  area  in  the  stomach,  for  exaniple,  may  suggest 
the  thickening  of  its  walls  due  to  a  malignant  disease ;  some  displace- 
ments or  adhesions  may  be  recognized,  as  well  as  hour-glass  contrac- 
tions, or  an  unusual  delay  of  the  digestive  process. 

X-ray  photographs  do  not  show  the  movement  of  the  stomach  which 
takes  place  from  expiration  to  deep  inspiration.  The  photographic 
plate,  or  the  screen,  whichever  is  employed,  should  be  placed  over  the 
abdomen,  not  on  the  back,  when  an  X-ray  examination  is  made. 

These  observations  are  preliminary  in  character,  and  merely  suggest 
some  of  the  ways  in  which  this  problem  may  be  approached. 

Physiology  of  Digestion.  —  The  process  of  digestion  has  been 
observed  carefully  and  independently  by  W.  B.  Cannon  ^  in  the  stomachs 
of  cats,  and  by  Roux  and  Balthazard^  in  the  stomachs  of  frogs, 
dogs,  and  men.  Bismuth  was  used  ais  a  means  of  defining  the  hmits 
of  this  organ.  The  peristaltic  movements  were  followed  and  the  dimi- 
nution in  size  observed  as  digestion  went  on.  These  observers  found 
that  the  stomach  divided  itself  physiologically  into  two  parts  ;  that  the 
larger  cardiac  area  serves  as  a  reservoir  for  food,  and  the  smaller 
lower  area,  by  its  strong  peristaltic  movements,  serves  to  force  the  food 
into  the  duodenum.  The  experiments  showed  further,  that  these  regu- 
lar peristaltic  movements  ceased  if  the  animal  were  disturbed  (Cannon), 
and  it  seems  probable  that  the  same  effect  might  be  produced  in  human 
beings  if  the  nervous  system  were  profoundly  affected  during  the  diges- 
tive process.  i 

Roux  and  Balthazard  also  found  that  as  a  rule,  in  dogs  and  men,  the  »i 
liquids  with  which  they  experimented  began  to  be  evacuated  from  the  I 
stomach  into  the  duodenum  only  two  or  three  minutes  after  they  had 

i"The  Movements  of  the  Stomach  studied  by  Means  of  the  Roentgen  Rays,"  American  j 
Jourual  of  Physiology,  Vol.  I,  May  I,  1898. 

2  Comptes  rendtis  de  la  soc.  de  hiologie.  1S97,  l°  S>  'V'  PP-  567-569,  704-706,  785-787, 
and  Archives  de  physiologic,  1898,  5  S,  x,  pp.  85-94. 


CESOPHAGUS,   ABDOMEN,    AND    PELVIS  2)7 Z 

entered  the  stomach  ;  whereas  certain  solids  remained  in  the  stomach 
for  a  long  time,  and  that  the  pylorus  remained  closed  so  that  nothing 
could  pass  into  the  duodenum. 

Digestive  Tract  observed  by  Means  of  Capsules.  —  Boas  and  Levy- 
Dorn  ^  gave  a  patient  capsules  covered  with  celluloid,  to  prevent  them 
from  dissolving,  and  filled  with  bismuth  to  make  them  obstructive  to 
the  X-rays,  and  then  watched  their  progress  through  the  digestive 
tract  by  means  of  the  fluorescent  screen.  The  capsules  were  2.25  centi- 
metres long,  1.25  centimetres  thick,  and  weighed  12  grammes.  In  cases 
of  slight  stomach  trouble  the  capsule  was  usually  found  in  the  cecum  at 
the  end  of  twenty-four  hours ;  if  the  pyloric  orifice  was  much  contracted 
the  capsule  lay  for  days  in  the  stomach.  The  writers  think  this  method  a 
valuable  one  for  discovering  the  presence  of  a  contracted  opening,  and 
for  distinguishing  this  condition  from  dilatation  of  the  stomach.  If 
there  is  no  contraction  present  the  capsule  passes  off  naturally. 

The  size  and  position  of  the  cardiac  end  of  the  stomach  can  be  deter- 
mined by  sounds  with  metallic  tips  ;  the  metal  enables  the  observer  to 
recognize  the  position  of  the  cardiac  orifice  because  of  the  obstruction  it 
offers  to  the  X-rays. 

Liver 

The  outline  of  the  upper  and  lower  border  and  of  the  left  lobe  of  the 
liver  may  be  followed  in  children  by  means  of  the  X-rays,  and  also  in 
many  adults  under  suitable  conditions ;  but  as  a  rule,  although  the 
upper  border  of  the  liver  of  adults  can  be  determined  with  certainty  on 
the  fluorescent  screen,  the  lower  border  can  generally  be  better  deter- 
mined by  the  usual  methods.  Enlargements  of  the  liver,  or  changes  in 
its  outline,  if  they  affect  the  diaphragm,  may  be  recognized  by  the  rays, 
but  the  observer  should  be  very  careful  in  his  interpretation  of  the 
appearances  seen  on  the  screen.  Echinococci  of  the  liver  sometimes 
escape  into  the  thoracic  cavity,  and  may  there  be  recognized  by  means 
of  the  X-rays,  and  thus  the  attention  of  the  practitioner  be  directed  to 
the  correct  diagnosis.     (See  Chapter  XII  on  New  Growths.) 

Spleen 

The  lower  border  of  the  spleen  can  be  most  easily  recognized  by 
distending  the  large  intestine  with  air,  as  in  this  way  the  neighboring 

' "  Zur  Diagnostik  von  Magen  u.  Darmkrankheiten  niittels  Roentgenstr.,"  Deutsche  Med. 
Wochenschr.,  January  13,  1898,  p.  18. 


174 


THE    ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 


organs  are  displaced  and  this  border  is  therefore  brought  into  contrast 
with  the  light  area  produced  by  the  air.  The  upper  border,  where  it 
lies  against  the  diaphragm,  can  be  determined  for  all  practical  purposes 
by  determining  the  position  of  that  portion  of  the  diaphragm. 

The  spleen  of  children  can  be  seen  very  well  on  the  screen,  and  the 
motion  its  shadow  describes  during  a  full  inspiration  shows  that  it  not 
only  descends  with  the  diaphragm,  but  that  its  anterior  border  moves 
more  than  its  posterior  border,  and  that  the  spleen  is  turned  about  its 
long  axis ;  on  the  screen  it  has  the  appearance  of  turning  a  somersault. 

Kidneys 

An  X-ray  examination  may  be  of  service  in  renal  diseases  by  showing 
the  size  and  position  of  the  kidneys,  especially  that  of  the  left  one,  as 
this  is  more  easily  photographed  than  the  right,  because  a  large  part  of 
the  outline  of  the  latter  is  very  much  obscured  by  the  superimposed 
liver ;  second,  by  indicating  the  serious  nature  of  the  renal  disease  by 
appearances  in  the  lungs ;  and  third,  by  pointing  out  renal  calculi. 
This  latter  point  will  be  especially  considered  in  the  chapter  on  Calculi. 

Renal  Disease.  —  The  X-rays  indicate  the  presence  of  oedema  of  the 
lungs  in  renal  disease  by  showing  that  the  bases  of  these  organs  are 
darkened  on  the  fluorescent  screen,  before  it  is  recognized  by  a  physical 
examination.  They  also  show  that  the  outlines  of  the  other  organs  in 
the  thorax  are  sometimes  very  ill  defined  in  this  disease.  Therefore  by 
X-ray  examination  of  the  lungs  in  renal  disease  we  may  sometimes  get 
an  indication  of  the  serious  condition  of  the  patient.  The  following 
cases  will  illustrate  this  point :  — 

Case  I.  E.  C,  forty-seven  years  old.  September,  1896.  Chronic 
diffuse  nephritis.  For  three  months  this  patient  suffered  from  dyspnoea, 
which  steadily  increased.  My  X-ray  examination  showed  the  chest  to 
be  uniformly  dark  throughout,  except  at  the  apices,  where  the  first  and 
second  ribs  could  be  fairly  well  made  out.  The  outlines  of  the  dia- 
phragm and  of  the  heart  could  not  be  seen.  The  appearances  by  X-ray 
examination  suggested  oedema  of  the  lungs,  but  the  record  of  the  physi- 
cal examination  made  by  her  physician  on  the  following  day,  with  this 
in  view,  did  not  disclose  this  condition.  This  patient  suffered  from 
increasing  dyspnoea  and  orthopnoea,  and  died  one  week  later. 

Case  II.  A.  B.,  fifty  years  old,  came  to  me  for  consultation.  He 
was  known  to  have  a  chronic  renal  disease.  X-ray  examination  showed 
the  lungs  to  be  much  less  clear  than  in  health.     Although  he  attended 


CESOPHAGUS,   ABDOMEN,   AND    PELVIS  375 

regularly  to  his  business,  and  there  had  been  no  recent  symptoms  to 
cause  unusual  anxiety  to  him  or  to  his  physician,  nevertheless,  on  the 
evidence  of  an  X-ray  examination,  I  warned  him  that  it  would  be  wise 
for  him  to  put  his  affairs,  which  involved  large  business  interests,  in 
order.     About  three  months  later  he  died. 

It  will  thus  be  seen  that  the  X-rays  may  be  of  service  in  examina- 
tions of  the  kidneys,  directly,  as  first  stated,  and  indirectly,  by  pointing 
out  more  emphatically  than  other  methods  of  examination  an  abnor- 
mal condition  of  the  lungs,  thus  giving  warning  which  would  enable 
the  physician  to  afford  relief  by  suitable  treatment,  or,  where  this 
cannot  be  done,  to  put  the  patient  on  his  guard  in  relation  to  his 
affairs. 

Ascites 

In  ascites,  when  the  patient  is  lying  on  his  back  and  the  rays  pass 
through  him  from  side  to  side,  the  abdomen  may  be  seen  to  be  divided 
into  an  upper,  lighter  area,  and  a  lower,  dark  area,  the  upper  border  of 
the  lower  area  being  a  horizontal  line,  the  level  of  the  ascitic  fluid. 
This  line  remains  level  even  when  the  patient  changes  his  position.  By 
pushing  the  side  of  the  abdomen  quickly  the  line  of  fluid  may  be  dis- 
turbed. Above  the  fluid  the  abdominal  cavity  is  not  uniformly  lighter, 
but  the  moving  shadows  crossing  it  suggest  that  the  intestines  are 
changing  their  direction. 

Ascitic  fluid  or  gas  in  the  abdomen  or  a  new  growth  may  push  up 
the  diaphragm  and  make  its  outline  abnormal.  The  excursion  of  the 
diaphragm  may  also  be  limited. 

New  Growths 

New  growths  in  the  abdomen  are  not  easily  recognized  by  an  X-ray 
examination.  We  may  get  some  suggestion  of  their  presence  if  they 
affect  the  outline  of  the  diaphragm.  Or  if  the  growth  is  well  marked 
and  dense,  it  may  cast  a  shadow  on  the  fluorescent  screen  or  be  seen  in 
the  negative.  New  growths  near  the  diaphragm  (for  example,  affecting 
the  liver)  may  push  up  the  diaphragm  on  this  side  or  change  its  outline. 
That  is,  during  expiration  the  diaphragm  may  go  up  into  the  thoracic 
cavity  with  a  sharper  curve  than  in  health.  Or,  during  full  inspiration 
the  outline  of  the  diaphragm  may  not  have  its  usual  curve,  and  its  outline 
may  be  less  regular  than  normal,  as  if  it  wrapped  itself  about  something 
of  abnormal  shape.     Also  the  presence  of  any  unusual  mass  just  below 


376   thp:  roentgen  rays  in  medicine  and  surgery 

the  diaphragm  may  affect  the  position  of  the  heart  (see  chapter  on 
Heart),  for  example,  and  the  long  axis  of  this  organ  may  be  made  more 
horizontal  than  usual. 

Carcinoma  of  the  Stomach.  —  In  one  case  of  carcinoma  of  the  stom- 
ach I  noticed  that  the  median  end  of  the  diaphragm  on  the  right  side 
did  not  have  as  long  an  excursion  on  its  inner  half  as  on  its  outer  half, 
and  that  its  outline  was  changed  in  a  way  to  suggest  that  some  ob- 
struction underneath  it  prevented  its  descent  to  as  low  a  point  as  usual. 


B  B 
Cancer  of-  Litter 
^ bnonnfl/ Oi//f/jje  of  f^/r/Af  V/noAri^m 


e 


Fio.  213.  B.  B.  Cancer  of  liver.  Cut  of  X-ray  tracing.  Auscultation  and  percussion  indicated 
to  the  physician  of  the  patient  extension  of  the  disease  into  the  thoracic  cavity.  My  X-ray  examination 
showed  no  evidence  of  this  extension.  Broken  line  and  full  line  below  it  show  abnormal  outline  of 
diaphragm  in  expiration  and  inspiration  respectively.      (Cut  one-third  life  size.) 


While  it  is  far  more  difficult  to  recognize  a  new  growth  in  the 
abdominal  cavity,  by  an  X-ray  examination,  than  when  it  is  situated 
in  the  thorax,  yet  there  are  cases  in  which  we  may  be  guided  by  this 
method  in  determining  whether  or  not  the  disease  in  the  former  region 
has  extended  above  the  diaphragm.     For  example  :  — 

Carcinoma  of  the  Liver.  —  Bernard  B.,  thirty-nine  years  old  ;  patient 
of  one  of  my  colleagues ;  was  suffering  from  carcinoma  of  the  liver. 
The  examination  by  auscultation  and  percussion  indicated  to  his  physician 


(ESOPHAGUS,   ABDOMEN,   AND    PELVIS  t^']'j 

that  the  disease  had  extended  into  the  thoracic  cavity.  By  X-rayf 
examination,  however,  I  found  no  evidence  of  such  extension  ;  the  lung 
was  clear  in  this  region.  This  case  is  also  referred  to  in  the  chapter 
on  New  Growths. 

Cancer  of  the  Pylorus.  —  I  examined  the  following  case  with  the 
X-rays,  with  the  result  noted  below  :  — 

Ruth  A.  G.,  forty  years  old,  entered  the  hospital  March  lO,  1898. 
Diagnosis  :  cancer  of  the  pylorus. 

A  hard,  resistant  mass,  oval  in  shape,  7.5  centimetres  long  by  5 
centimetres  wide,  its  middle  point  about  5  centimetres  to  the  right  of 
the  umbilicus,  could  be  easily  felt.  The  stomach  was  distended  on 
account  of  this  obstruction,  and  this  distension  was  obvious  both  to  the 
eye  and  to  the  hand. 

An  examination  with  the  fluoroscope  showed  an  area  darker  than 
normal  over  the  site  of  the  mass  above  described,  but  nothing  was 
gained  by  the  X-ray  examination  that  was  not  more  easily  got  by 
other  methods. 

Any  conditions  which  give  rise  to  marked  contrasts  in  density  would 
offer  some  opportunity  for  X-ray  examination.  I  recall  among  others 
a  patient  whom  I  was  examining  with  the  fluorescent  screen,  whose 
abdomen  was  much  distended  by  gas.  When  he  was  lying  on  his  back 
with  the  light  going  through  the  abdomen  from  side  to  side,  the  picture 
on  the  screen  was  made  up  of  two  areas,  the  lower  of  which  was  dark 
and  the  upper  light.  As  I  watched  the  screen,  I  saw  a  dark  mass 
about  the  size  of  a  closed  hand  appear  from  time  to  time  above  the 
dark  area  on  the  screen,  and  move  across  the  light  upper  half  of  the 
picture,  and  then  disappear  again,  moving  from  the  end  of  the  screen, 
near  the  back  of  the  pelvis,  toward  the  front  of  the  abdomen.  This 
mass  seemed  to  be  undoubtedly  connected  with  the  intestine,  but  my 
experience  in  this  direction  was  too  limited  to  go  farther  than  this. 
Abdominal  section  by  the  surgeon  showed  the  object  to  be  a  mass  of 
malignant  disease  connected  with  the  intestine. 

Phantom  Tumors.  —  Patients  with  phantom  tumors  should  always  be 
examined  by  the  X-rays,  whenever  practicable,  with  the  light  going 
through  the  abdomen  from  side  to  side  as  well  as  antero-posteriorly, 
for  if  the  apparent  tumor  is  caused  by  gas,  a  bright  area  would  be  seen 
on  the  screen,  and  the  presence  of  a  dense  tumor  would  be  precluded. 

New  growths  in  the  abdomen  may  be  recognized  by  means  of  X-ray 
examination,  but,  as  a  rule,  at  so  advanced  a  stage  that  their  presence 


^•jS     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

has  already  been  made  probable  by  other  means  of  investigation.  But 
as  progress  is  made  in  methods  of  examination  for  this  part  of  the  body, 
much  more  may  be  done  than  is  at  present  practicable. 

The  question  of  the  treatment  of  carcinoma  by  the  X-rays  is  dis- 
cussed in  the  chapter  on  the  Therapeutic  Uses  of  the  X-Rays. 

Intestines    (See  also  Appendix) 

Insoluble  capsules  containing  opaque  substances  may  be  given  to 
the  patient,  as  we  have  just  seen,  and  their  passage  through  the  intes- 
tines watched.  It  is,  however,  not  possible  to  determine  exactly  in 
which  part  of  the  small  intestines  the  capsules  may  be,  as  the  folds 
lie  so  much  over  one  another. 

To  determine  by  means  of  such  capsules  whether  or  not  a  stricture 
is  present  in  some  part  of  the  intestines  would  hardly  be  a  wise  pro- 
cedure, since  the  capsule  might  plug  the  opening,  and  thus  cause 
serious  trouble,  unless  preparation  had  been  made  for  operation.  In 
this  case  the  capsule  might  help  the  surgeon  to  find  the  site  of  the 
stricture. 

The  large  intestine  may  be  injected  with  fluid  containing  an  opaque 
substance  like  subnitrate  of  bismuth,  and  its  outline  and  position  studied. 
I  think,  however,  that  we  should  remember  that  any  liquid  which  is 
opaque  to  the  rays  must  be  heavy,  and  that  the  risk  of  putting  into  the 
large  intestine  such  a  weight  as  might  be  dangerous  to  its  integrity 
should  not  be  taken. 

Another  method  for  determining  the  position  of  the  large  intestine 
is  —  after  the  bowels  have  been  emptied  by  a  mild  cathartic  —  to  inject 
air  into  the  intestine,  and  thus  distend  it.  Its  position  is  then  recognized 
on  the  fluorescent  screen  by  the  light  area. 

A  sigmoid  flexure  and  a  descending  colon  which  are  distended  with 
gas  may  show  their  position  and  sacculated  outline  with  surprising 
distinctness  in  a  radiograph. 

Pelvis 

It  may  be  of  importance  to  know  the  size  of  the  pelvic  inlet  and 
to  be  able  to  determine  whether  it  is  narrower  than  normal  on  account 
of  malformation  of  the  pelvis  or  of  bony  changes ;  and  this  information 
can  now  be  obtained  by  the  X-rays. 

Bouchacourt  ^  states  that  the  photograph  can  show  now  almost  with 

1  "De  la  radiographic  du  bassin  de  la  femme  adulte,"  H  Obstet.,  Paris,  1900,  v,  pp.  20-34. 


CESOPHAGUS,    ABDOMEN,    AND    PELVIS  379 

certainty  whether  there  is  or  is  not  a  deformity  of  the  pelvis  ;  whether 
it  is  symmetrical  or  unsymmetrical ;  and  finally,  what  the  cause  of  the 
deformity  is. 

Method  for  taking  a  Photograph  of  the  Pelvis.  —  When  the  size  of 
the  brim  of  the  pelvis  is  desired,  the  patient  may  rest  on  the  plate  in  a 
sitting  position,  leaning  somewhat  backwards ;  the  tube  in  this  case  is 
placed  above  and  in  front  of  her ;  or  the  patient  may  be  on  her  back 
with  the  thighs  drawn  up  and  the  plate  under  the  tuberosities  of  the 
ischii,  and  as  nearly  as  possible  in  a  plane  at  right  angles  to  the  a.xis  of 
the  pelvis.  The  tube  is  placed  above  the  patient  in  a  line  with  the 
pelvic  axis. 

Trendelenburg  Position.  —  Freund  ^  found  that  the  Trendelenburg 
position  was  a  convenient  one  for  photographing  the  pelvis,  as  in  this 
position  the  vascular  intestinal  coils,  etc.,  fall  toward  the  diaphragm, 
and  therefore  the  X-rays  have  freer  passage. 

Sacrum. — When  a  photograph  of  the  sacrum  is  desired  it  is  best 
to  place  the  patient  in  a  prone  position,  with  the  plate  under  her  and 
the  tube  above  her. 

Measurement  of  Transverse  Diameter  of  the  Pelvis.  —  In  order  to 
determine  the  transverse  diameter  of  the  superior  brim  of  the  pelvis, 
I  have  devised  the  following  method  by  which  the  two  halves  of  the 
pelvis  are  taken  separately  but  on  the  same  photographic  plate.  The 
patient  lies  on  her  back  on  the  stretcher,  with  the  plate  over  the 
abdomen  and  the  inlet  of  the  pelvis  about  parallel  with  the  plate. 
When  the  right  side  of  the  pelvis  is  being  taken,  the  left  half  of  the 
plate  is  shielded  by  a  sheet  of  lead  placed  under  the  plate.  The  tube 
is  placed  by  means  of  a  plumb-line  as  nearly  as  possible  directly  under 
the  right  border  of  the  superior  brim  of  the  pelvis,  in  the  line  of  the 
pelvic  axis,  3  centimetres  to  the  right  of  the  median  line.  If  the  tube 
is  at  least  60  centimetres  from  the  plate,  and  as  nearly  as  possible  just 
above  the  point  the  position  of  which  we  wish  to  determine,  the  error  in 
the  photograph  will  not  be  great.  After  the  first  exposure  has  been 
made  and  the  left  side  of  the  pelvis  is  to  be  photographed,  the  sheet 
of  lead  is  moved  so  as  to  cover  the  right  half  of  the  plate,  and  the 
tube  is  placed  immediately  over  the  left  edge  of  the  superior  outlet  of 
the  pelvis,  3  centimetres  to  the  left  of  the  median  Hne,  its  proper 
position  being  obtained,  as  before,  by  means  of    the  plumb-line  ;    the 

^  Report  of  paper  read  before  the  Societv  for  the  Diffusion  of  Scientitic  Knowledge  in 
Vienna.     British  Medical  Journal,  1899,  Vol.  II,  Epitome,  p.  85. 


38o    THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


CESOPHAGUS,   ABDOMEN,    AND    PELVIS 


381 


382     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

photographic  plate  is  not  disturbed.  An  exposure  is  then  made  of  this 
part,  and  thus  a  photograph  of  the  two  sides  of  the  brim  of  the  pelvis 
is  obtained.  (See  Fig.  214.)  By  this  method  the  error  due  to  the 
slanting  direction  of  the  rays  falling  on  the  pelvic  brim  and  the  plate 
when  only  one  exposure  is  made  for  both  sides,  is  avoided,  and  no 
calculation  is  necessary  to  estimate  the  amount  of  exaggeration  as  in 
the  latter  case.  Figure  215  illustrates  the  error  resulting  when  only  one 
exposure  is  made.  Figures  214  and  215  are  cuts  of  the  same  pelvis, 
but  there  is  a  difference  between  their  widths  of  1.5  centimetres.  The 
correct  width  is  that  obtained  from  Fig.   214. 

Gravid  Uterus.  —  Some  observers,  notably  Dr.  Edward  P.  Davis, 
have  succeeded  in  taking  an  X-ray  photograph  of  a  gravid  uterus ;  and 
one  case  at  least  has  been  reported  ^  in  which  the  X-rays  confirmed  the 
diagnosis  of  extra-uterine  pregnancy,  the  X-ray  photograph  showing  a 
foetus  5  or  6  months  old. 

Drs.  Varnier  and  Pinaud^  have  studied  the  gravid  uterus  in  dead 
and  living  women  by  means  of  the  rays.  In  one  patient  who  died  of 
pulmonary  congestion,  the  photographic  plate  showed  the  outline  of 
the  uterus,  and  within  it  the  vertebral  column  of  the  fcetus.  In  another 
who  died  of  eclampsia  when  the  foetus  was  7  months  old,  the  right 
border  of  the  uterus  was  pressed  toward  the  left  and  the  head  of  the 
foetus  was  presented  at  the  superior  strait. 

They  also  made  X-ray  photographs  of  the  gravid  uterus  in  sixteen 
living  women ;  seven  had  been  pregnant  from  2  to  4^  months,  and 
nine  from  5  to  jh  months.  The  conclusions  drawn  from  these  cases  were 
as  follows  :  The  maternal  pelvis  can  be  completely  seen  up  to  4^  months, 
and  more  clearly  the  earlier  the  photograph  is  taken  :  but  of  the  uterus  and 
its  contents  no  trace  is  perceived.  These  latter  are  traversed  with  such 
ease  by  the  rays  that  they  do  not  interfere  with  the  study  of  the  pelvis. 
After  5  months  the  uterus  and  its  contents  form  on  the  negative  a 
veil,  as  it  were,  which  is  badly  defined  and  without  definite  contour, 
but  which  conceals  the  posterior  wall  of  the  pelvis  and  the  vertebral 
column.  In  two  cases  a  pale  silhouette  of  the  foetal  head  could  be 
dimly  divined  in  the  pelvic  area. 

In  a  second  series  of  seven  cases  examined  from  April  23  to  Octo- 
ber 20,  1898,  the  same  results  (that  is  to  say,  negative)  were  obtained 

1  Turbert,  Lancet,  London,  1898,  June  5,  p.  1782. 

2  "  Radiographic  de  I'uterus  gravide,"  Ann.  de  Gynec.  et  (f  Ohstet.,  Paris,  1899,  li,  pp. 
278-289. 


CESOPHAGUS,   ABDOMEN,   AND    PELVIS  383 

whether  the  foetus  was  alive  or  dead.  Two  of  these  patients  had  been 
pregnant  from  2  to  3  months,  and  five  from  5  to  8  months. 

In  the  living  patient  the  head  of  the  foetus  can  be  photographed 
at  the  opening  of  the  pelvis  as  well  at  6\  months  as  at  the  approach  of 
full  term,  and  the  size  of  the  foetus,  its  orientation,  and  the  amount  of 
flexion  and  engagement,  can  be  estimated.  In  such  photographs,  taken 
with  the  patient  in  the  reclining  posture,  neither  the  vertebral  column 
nor  the  limbs  of  the  foetus  are  seen. 

Drs.  Varnier  and  Pinaud  are  still  prosecuting  their  study  of  the 
gravid  uterus. 

Determination  as  to  whether  a  Foetus  has  or  has  not  breathed.  — 
X-ray  examinations  may  be  of  service  to  determine  whether  a  child  has 
or  has  not  breathed.  Walsham  found  the  lungs  opaque  in  a  foetus 
I  which  had  not  breathed. 


CHAPTER    XV 

CHILDREN.     CALCIFICATION    OF    TISSUES.     ANEMIA.     PHYSIOLOGY 

Children 

The  X-rays  afford  excellent  opportunity  for  examining  children  and 
infants.  Their  smaller  size  makes  them  especially  suitable  for  this 
method  of  investigation.  All  parts  of  infants  and  children  are  far  more 
readily  accessible  than  those  of  adults,  not  only  the  thoracic  cavity,  but 
also  the  abdomen  and  the  head.  We  see  easily  the  outlines  in  the 
thoracic  cavity,  and  we  can  follow  the  outline  of  the  liver,  spleen,  and 
left  kidney,  the  last  particularly  when  the  patient  lies  on  the  face  with 
the  fluorescent  screen  on  the  back.  All  the  joints,  especially  the 
shoulder  and  hip  joints,  are  far  more  easily  photographed  than  those  of 
the  adult.  In  examining  the  thorax,  indeed,  care  must  be  taken  to  avoid 
too  much  light,  for  the  organs  in  the  chest  of  a  young  child  are  so  easily 
traversed  by  the  rays  that  if  the  light  is  too  strong  the  border  of  the 
heart,  for  instance,  would  not  be  well  defined  because  the  edges  would 
be  penetrated  by  the  rays,  and,  therefore,  the  shadow  of  the  heart  cast 
on  the  screen  would  be  smaller  than  the  heart  itself. 

I  think  there  can  be  no  question  as  to  the  value  of  X-ray  examina- 
tions in  diseases  of  children.  While  the  difficulties  to  be  overcome  on 
the  part  of  the  physician  are  great,  the  inconvenience  to  the  patient 
is  slight,  in  fact  is  reduced  to  a  minimum.  Children  may  lie  down 
on  the  comfortable  stretcher  and  be  allowed  to  go  to  sleep,  as  they 
often  do.  They  may  then  be  examined  with  the  fluorescent  screen,  or 
an  X-ray  photograph  may  be  taken  without  disturbing  them.  Or,  if  the 
child  objects  to  lying  down,  he  may  be  held  in  his  mother's  arms  in  a 
suitable  position.      It  is  not  always  necessary  to  remove  the  clothing. 

The  X-ray  examination  is  an  excellent  means  of  supplementing  other 
methods  of  examination  in  children,  and  deserves  careful,  patient,  and 
thorough  study.  It  has  already  proved  to  be  of  service  in  surgical  cases, 
such  as  in  diseases  involving  the  bones  ;  for  example,  in  the  recogni- 
tion   of    hip    disease  or    other    tuberculous    conditions,   malformations, 

384 


TISSUES,   ANEMIA,   PHYSIOLOGY  385 

displacements,  fractures,  delayed  union  of  epiphyses,  rickets ;  and 
I  am  convinced  that  those  who  choose  to  cultivate  this  field  on 
the  medical  side  will  find  their  patience  well  rewarded.  For  instance, 
in  some  cases  of  pneumonia,  especially  in  the  early  stages,  we  cannot 
detect  the  presence  of  pneumonic  areas  in  infants  and  children,  nor  in 
adults,  as  has  been  shown,  by  the  usual  methods;  in  these  cases  a 
doubtful  diagnosis  may  be  made  more  certain  by  an  X-ray  examination. 
See  chapter  on  Pneumonia,  Clara  B.,  page   184. 

Again,  in  young  patients  with  symptoms  which  suggest  tuberculous 
meningitis,  it  may  be  desirable  to  have  a  careful  X-ray  examination  of 
the  lungs,  with  a  view  to  determining  whether  or  not  tuberculous  foci 
exist  there. 

It  is  unnecessary  to  give  special  directions  for  making  X-ray  exami- 
nations of  children,  as  the  same  general  rules  hold  for  them  as  for  adults. 
Especial  care  should  be  taken,  however,  when  a  child  is  to  be  examined, 
that  everything  is  in  readiness,  in  order  that  the  examination  may  be 
completed  in  a  few  moments,  before  he  has  had  time  to  get  restless. 

Children  may  be  examined  with  a  smaller  and  less  expensive  appa- 
ratus than  is  required  for  adults,  and  I  think,  eventually,  in  hospitals 
for  children  and  infants,  an  X-ray  examination  will  be  made  in  many 
cases  a  part  of  the  routine. 

Calcification  of  the  Tissues 

It  has  been  stated  in  the  first  chapter  that  the  permeability  of  a 
substance  depends  partly  upon  its  chemical  composition,  and  it  is  evi- 
dent from  the  data  there  given  that  when  the  salts  of  calcium  are  found 
in  the  soft  tissues  they  would  be  less  easily  traversed  by  the  rays,  and 
if  the  situation  is  a  favorable  one  for  taking  a  radiograph,  this  change 
in  composition  would  be  very  evident.  In  the  pleurae,  in  the  lungs, 
and  in  the  arteries  we  find  calcification  which  can  frequently  be  recog- 
nized. The  sHght  amount  of  calcification  which  would  show  on  a  radio- 
graph of  the  arteries  of  the  extremities  would  not  be  apparent  if  it  were 
in  the  ascending  aorta,  but  well-marked  calcification  of  portions  of  the 
aorta  can  be  seen  on  the  negative  and  even  on  the  fluorescent  screen  ; 
a  dark  area  due  to  marked  calcification  of  the  ascending  aorta,  for 
example,  may  cast  a  shadow. 

I  have  observed  a  darkened  area  on  the  fluorescent  screen  over  the 
site  of  what  was  shown  to  be,  soon  after,  by  2.  post-uiortcni  examination, 
a  marked  calcification  of  the  aorta.     It  has  been  stated  that  it  is  possible 


386     THE    ROENTGEN    RAYS    IN    iMEDICINE    AND    SURGERY 

to  recognize,  by  an  X-ray  examination,  calcification  of  the  coronary 
arteries,  but  this  seems  to  me  at  present  impracticable. 

If  a  radiograph  of  the  aorta  in  its  early  portion  is  desired,  the  plate 
should  be  placed  on  the  front  of  the  chest ;  when  of  other  portions  of 
the  aorta  it  is  better  to  place  the  plate  on  the  patient's  back. 

The  two  following  cuts  illustrate  the  appearances  seen  when  calcifi- 
cation of  the  tissues  has  taken  place  :  — 


Fig.  2i6.     Calcification  of  radial  artery  in  a  man  thirty-seven  years  old. 


Normal  Blood  Vessels.  —  Normal  blood  vessels  cannot  be  so  easily 
recognized  as  when  they  are  calcified,  but  it  is  quite  possible  to  recog- 
nize in  individuals,  both  young  and  old,  normal  arteries  by  means  of 


TISSUES,    ANEMIA,    PHYSIOLOGY 


^87 


X-ray  photographs ;  for  example,  the  dorsalis  pedis,  the  popHteal 
artery,  or  the  bracheal  artery  and  its  division  into  the  ulnar  and  radial 
arteries.     I  have  radiographs  of  normal  arteries  in  the  extremities  taken 


Fig.  217.     Calcified  pleura  and  tuberculous  lung  taken  from  autopsy. 

in  1896,  and  also  radiographs  showing  the  outlines  of  the  thoracic  aorta, 
both  the  ascending  and  descending  portion,  and  the  superior  vena  cava. 
The  right  border  of  the  latter  and  of  the  ascending  aorta  can  be  fol- 
lowed in  the  radiograph  for  a  considerable  distance. 


388     THE   ROENTGEN    RAVS    IN    MEDICINE   AND    SURGERY 

ANtEMIA 

I  have  examined  eleven  cases  of  anaemia  in  young  women,  by  the 
X-rays,  and  in  six  of  these  found  no  marked  departure  from  the  normal 
by  this  method.  In  five  of  them  the  appearances  varied  from  the 
normal. 

In  one  of  these  the  upper  portion  of  the  left  lung  was  darker  than 
normal  and  the  excursion  of  the  diaphragm  was  shorter  on  this  side 
than  on  the  other  side.  Four  days  later  the  excursion  of  the  diaphragm 
had  increased  and  the  darkened  area  in  the  upper  portion  of  the  left 
lung  was  less  marked.  Ten  days  after  the  first  examination  the  dark- 
ened area  in  the  left  lung  had  disappeared,  and  the  excursion  of  the 
diaphragm  was  greater  than  on  the  right  side. 

In  the  second  case  the  excursion  of  the  diaphragm  was  limited  on 
both  sides  ;  in  this  patient  only  one  examination  was  made. 

In  the  third  patient  the  excursion  of  the  diaphragm  on  each  side 
was  only  2  centimetres.  Eleven  days  later  it  had  increased  to  5  centi- 
metres. 

The  fourth  patient  entered  the  hospital  with  a  diagnosis  of  debility 
and  pregnancy.  The  X-ray  examination  showed  that  the  whole  of  the 
left  lung  was  darker  than  normal  and  the  excursion  of  the  diaphragm 
could  not  be  made  out ;  on  the  right  side  the  excursion  of  the  diaphragm 
was  only  2  centimetres,  and  the  upper  portion  of  the  right  lung  as  far 
as  the  third  rib  was  darker  than  normal.  These  appearances  seemed 
to  indicate  pulmonary  tuberculosis,  but  the  patient  had  a  normal  tem- 
perature and  did  not  react  to  tuberculin.  Twenty-seven  days  later  the 
appearances  in  the  chest  had  improved  very  much.  The  excursion  of 
the  diaphragm  on  the  right  side  was  7  centimetres,  on  the  left  side  4.7 
centimetres,  and  only  a  slight  shading  of  the  upper  part  of  the  left  lung 
remained.  This  case  shows  the  importance  of  a  second  X-ray  examina- 
tion made  after  an  interval  of  time. 

In  the  fifth  patient,  the  excursion  of  the  diaphragm  during  deep 
inspiration  was  less  than  normal  and  the  heart  was  smaller  than  normal. 

Small  Hearts.  —  In  four  out  of  seven  patients  suffering  from  ancemia 
that  I  examined  with  the  X-rays  I  found  the  heart  was  smaller  than  normal. 
The  ability  to  recognize  with  certainty  this  condition  may  be  of  much 
service  to  the  patient  in  both  treatment  and  prognosis. 

Error  possible  as  to  Width  of  Heart  by  Ordinary  Methods.  —  In 
anaemia  with  constipation  we  may  be  deceived  by  the  ordinary  methods 


TISSUES,   AN.BMIA,    PHYSIOLOGY  389 

as  to  the  size  of  the  heart ;  it  may  seem  wider  than  normal  if  the 
diaphragm  is  higher  up  in  the  chest  than  in  health.  After  suitable 
treatment,  in  such  cases,  with  laxati\^es  and  iron,  the  width  of  the  heart 
by  the  usual  examination  seems  to  be  diminished,  but  the  X-rays  show 
that  the  size  of  this  organ  has  not  altered,  but  that  the  supposed 
enlargement  was  due  to  the  fact  that  the  axis  of  the  heart  was  more 
horizontal  than  normal  on  account  of  the  higher  position  of  the  dia- 
phragm.    (See  chapter  on  the  Heart,  pages  287,  288,  and  297.) 

Pernicious  Anaemia.  —  In  three  cases  the  excursion  of  the  diaphragm 
was  much  less  than  in  health.  In  one  of  them  an  X-ray  photograph  was 
made  of  both  legs.  The  tibiae  did  not  show  an  outline  indicating  the 
medullary  cavity,  although  this  was  quite  evident  in  both  fibulae.  This 
photograph  was  taken  in  order  to  see  if  any  changes  in  the  bone  marrow 
could  be  observed. 

Physiology 

In  physiology,  problems  relating  to  the  voice,  digestion,  and  respira- 
tion have  been  studied  by  means  of  the  X-rays,  and  Imbert  and  Bertin- 
Sans^  consider  that  they  are  of  great  value  in  the  study  of  articular 
movement. 

The  movements  of  the  stomach  during  digestion  have  been  dis- 
cussed in  the  chapter  on  the  Abdomen,  but  a  few  words  in  regard  to 
Scheier's^  investigations  concerning  the  voice  and  larynx  are  in  place 
here. 

Physiology  of  the  Voice  and  Speech.  —  Dr.  Max  Scheier  has  watched 
on  the  screen  the  motions  made  by  the  soft  palate  while  the  person 
observed  was  speaking ;  he  noticed  that  the  palate  rose  to  different 
heights  according  to  the  vowels  uttered  ;  least  when  "  a "  was  pro- 
nounced, a  little  higher  with  "  e,"  and  so  on  with  each  successive  vowel 
in  order,  rising  highest  with  "i";  the  shape  also  of  the  palate  varied 
according  to  the  vowels  spoken.  If  consonants,  with  the  exception  of 
the  semivowels  and  the  resonants,  were  pronounced,  the  palate  rose 
even  higher  than  with  "i,"  but  when  "m,"  "n,"  and  "  ng  "  were  uttered 
it  hardlv  moved.  If  the  vowels  were  spoken  in  a  nasal  tone  it  rose 
only  a  little  ;  if  the  tone  of  the  voice  were  high  it  rose  more  than  when 
the  tone  was  deep  ;  likewise  it  rose  higher  if  the  vowels  were  uttered  in 
a  loud  tone  of  voice  than  when  softly  spoken. 

'  Compt.  ic'iid.  Acad  d.  Sc,  Paris,  May  4,  1896,  p.  997. 

-  "  Weitere  Mittheilungen  iiher  die  Anwendung  der  Roentgenstrahlen  in  der  Rhino-  und 
Laryngol.igie,"   FortscliriUe  a.  d.    Geb    d.    Roentgenstr.,   B.   I,    1897-1898. 


390     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Effect  of  Excessive  Exercise  on  the  Heart.  —  T.  Schott  {Berlin,  klin. 
Woc/ioisc/irift,  May,  1897)  gives  X-ray  photographs  of  the  hearts  of 
children  from  twelve  to  fourteen  years  of  age  that  had  been  acutely 
dilated  by  wrestling  with  each  other  until  they  were  out  of  breath.  The 
photographs  show  a  widening  of  the  heart,  chiefly  in  the  region  of  the 
left  ventricle,  which  had  taken  on  a  special  form. 

Schott,  in  a  later  article  (Verhandlungen  des  Congresses  fiir 
Innere  Medicin,  April  11-14,  1899),  shows  by  pulse  tracings  and 
tracings  made  of  the  heart  before  and  after  exercise,  that  e.xc^.ssive 
exercise  makes  the  pulse  faster,  less  regular,  and  less  full,  and  that  it 
enlarges  the  heart.  Several  of  these  tests  were  made  on  individuals 
after  they  had  ridden  rapidly  several  kilometres  on  a  wheel. 


CHAPTER    XVI 
THERAPEUTIC    USES    OF   THE   X-RAYS 

The  accounts  given  in  the  medical  journals  of  the  therapeutic  uses 
of  the  X-rays  in  diseases  of  the  skin  have  seemed  to  many  practi- 
tioners beyond  belief.  It  is  surely  marvellous  that  certain  skin  affec- 
tions can  be  relieved  by  exposure  to  the  X-rays,  without  producing 
inflammation  or  causing  inconvenience  to  the  patient ;  but  sufficient 
evidence  has  now  been  accumulated  to  show  that  in  certain  fields  the 
X-rays  have  therapeutic  properties.  In  some  of  the  early  cases 
inflammation  and  dermatitis  were  produced,  and  even  more  serious 
injuries,  but  it  has  now  been  demonstrated  that  these  results  are  un- 
necessary if  proper  care  is  exercised.  In  order  to  show  the  good  results 
that  may  be  obtained,  as  well  as  the  care  that  should  be  taken  and  the 
dangers  to  be  avoided,  I  have  selected  a  few  cases  which  will  be  given 
later  to  illustrate  certain  points  that  should  be  borne  in  mind  when  using 
the  X-rays  as  a  therapeutic  measure. 

In  1897  Freund  ^  published  the  results  of  two  series  of  experiments 
in  the  treatment  of  hypertrichosis  with  the  X-rays.  In  one,  depilation 
was  produced  after  an  aggregate  exposure  of  twenty  hours,  without 
causing  any  noteworthy  inflammation  ;  in  the  other,  a  dermatitis  which 
took  on  the  character  of  a  necrosis  was  set  up  after  an  aggregate  expo- 
sure of  forty-four  hours.  This  production  of  inflammation  in  the  deeper 
layers  of  the  skin,  and  breaking  up  of  the  tissues,  suggested  the  use  of 
the  X-rays  to  Schiff  as  a  therapeutic  agent  in  the  treatment  of  lupus, 
and  two  cases  which  he  thus  treated  are  given  in  detail  in  the  Arc/iw 
fiir  Derm.  it.  Syph.,  B.  42,  1898.  In  one  case,  that  of  a  girl  fourteen 
years  old,  who  had  suffered  with  this  disease  since  she  was  three  years 
of  age,  the  lupus  tract  extended  on  the  dorsal  side  of  the  arm  from  the 
metatarso-phalangeal  joints  of  the  left  hand  to  within  a  hand's  breadth 
of  the  elbow  joint.  The  patient  was  protected  by  a  sheet  of  lead  where 
treatment  was  not  desired,  and  the  tube  was  placed  at  a  distance  of 
15-20  centimetres,  in  such  a  position  that  the  X-rays  fell  directly  upon 

1   Wiener  Med.   Wochenschr.,  1897,  and   with   Schiff,   189S,  No.  22,  p.   1058. 

39' 


392     THE   ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

a  portion  of  the  lupus  tract.  As  a  control,  when  the  part  of  the  arm 
near  the  elbow  was  being  treated,  the  tube  was  placed  opposite  the 
inner  side,  and  under  these  circumstances  the  X-rays  did  not  sufifi- 
ciently  penetrate  the  parts  to  affect  the  lupus. 

Before  further  considering  the  use  of  the  X-rays  in  this  disease  I 
think  it  will  be  instructive  to  take  up  briefly  their  action  on  the  skin. 

Normal  and  Abnormal  Skin.  —  Albers-Schonberg  ^  states  that,  on  the 
whole,  the  action  of  the  X-rays  on  the  normal  and  abnormal  skin  is 
similar.  After  a  shorter  or  longer  time  the  skin  becomes  slightly  yel- 
low, then  slightly  red ;  this  light  red  becomes  darker,  and  in  many  peo- 
ple a  slight  irritation  and  pricking  occur,  which  is  followed  by  a  burning 
sensation  that  in  sensitive  persons  grows  into  pain.  In  some  cases,  with 
this  increasing  redness  comes  a  slightly  oedematous  swelling  of  the  skin. 
If  the  skin  continues  to  be  exposed  to  the  X-rays  it  takes  on  an  ever 
darker  color,  and  excoriation  appears  which  in  a  few  days  spreads  over 
the  whole  of  the  X-rayed  portion  of  the  skin,  which  then  looks  as  if  it  had 
been  burned.  In  a  number  of  cases,  provided  the  X-rays  were  no  longer 
applied,  the  skin  healed  from  the  edge  toward  the  centre.  The  ten- 
dency to  heal  varied.  If  excoriation  had  followed  upon  the  oedematous 
condition  of  the  skin,  the  healing  was  very  slow.  The  new  skin  that 
formed  was  of  a  delicate  rose  color  and  very  thin,  and  it  was  months 
before  it  took  on  the  character  of  the  normal  skin.  Albers-Schonberg 
has  not  himself  seen  injuries  going  any  deeper  into  the  skin  than  to  the 
rete  malphigii.  He  has  observed,  like  others,  the  cumulative  action  of 
the  X-rays  on  the  skin. 

In  cases  in  which  hyperaemia  appeared,  as  well  as  sometimes  in 
other  cases,  a  peculiar  displacement  of  the  pigment  occurred  in  the 
X-rayed  spot.  The  centre  and  the  greater  part  outside  of  it  became 
perfectly  white  and  pigmentless,  but  scattered  over  it  were  single  pig- 
ment spots  resembling  freckles,  some  of  which  were  as  large  as  beans, 
while  the  edge  corresponding  to  the  outline  of  the  mask  was  colored 
of  a  strong  yellowish  brown.  This  displacement  of  the  pigment  lasted 
a  long  time,  often  for  months,  and  then  gradually  the  skin  became 
normal  in  color  again.  Hahn  and  Albers-Schonberg  state  that  it  is 
important  to  recognize  this  discoloration,  as  the  scattered  spots  of  pig- 
ment do  not  disappear  under  glass  pressure,  and  in  a  case  of  lupus, 
therefore,  might  be  mistaken  for  new  nodules  or  the  remains  of  old  ones. 

1  "  Uber  die  Behandlung  des  Lupus  und  des  chronichen  Ekzems  mit  Roentgenstrahlen," 
Fortschritte  a.  d.  Geb.  d.  Roenigenstr.,  B.  II. 


THERAPEUTIC   USES   OF   THE   X-RAYS  393 

Finger  Nails.  —  Hahn  and  Albers-Schonberg  also  observed  that  the 
finger  nails  were  affected  by  the  X-rays  ;  they  became  thin  and  brittle 
on  the  edge  and  were  bent  Hke  claws.  The  conditions  set  up  suggested 
to  them  that  here,  as  in  the  case  of  temporary  alopecia,  there  was  also 
a  disturbance  in  the  nutrition  of  the  parts. 

Mode  of  Action  of  the  X-Rays.  —  Schiff  thinks  that  the  violent  inflam- 
mation produced  in  lupus  is  sufficient  to  injure  the  life  conditions  of  the 
micro-organisms,  and,  therefore,  their  continuance;  Kummell,^  that  a 
specific  effect  is  not  produced  on  the  lupus  by  the  X-rays,  but  rather, 
perhaps,  an  electro-chemical  (Jankau)  or  tropho-neurotic  (Barthelemy) 
influence  lies  at  the  bottom  of  their  work  :  Gocht,^  that  while  the  arti- 
ficially non-infectious  and  harmless  inflammation  which  reaches  to  the 
subcutaneous  tissue  is  going  on,  an  annihilation  of  the  tubercle  bacilli 
and  healing  take  place.  In  harmony  with  this  idea  are,  he  thinks, 
observations  made  on  cases  of  lupus  in  which  erysipelas  occurred,  and 
following  this  disease  the  inflammatory  process  came  to  a  standstill,  and 
the  skin  quickly  formed  over  the  lupus  patches;  Albers-Schonberg'^ 
suggests  that  possibly  the  X-rays  have  a  direct  effect  on  tuberculous 
tissue,  an  effect  which  may  be  aided  by  a  hyperaemia  ;  but  he  thinks 
that  we  are  unwarranted  in  ascribing  a  healing  influence  to  the  acute 
dermatitis,  because  in  some  of  his  cases  of  lupus  the  nodules  dried  up 
and  disappeared  without  dermatitis.  My  experience  has  been  similar 
in  so  far  that  I  have  found  it  unnecessary  to  excite  dermatitis  when 
treating  cases  of  lupus. 

Apparatus.  — •  The  writers,  when  reporting  the  following  cases,  have 
given  certain  details  concerning  the  apparatus  used,  that  is  to  say,  the 
number  of  volts,  and  amperes,  and  sometimes  also  the  spark-length  of 
the  induction  coil  and  the  number  of  interruptions  per  minute  ;  but 
more  exact  information  is  needed  in  order  to  determine  the  amount  of 
X-rays  produced  in  the  tube  of  one  practitioner  as  compared  with  that 
of  another.     The  efficiency  of  different  coils  varies  very  much. 

The  resistance  of  the  tube  is  a  cardinal  factor  to  be  considered. 
There  is  no  wholly  satisfactory  way  known  at  present  of  measuring  the 
intensity  and  quality  of  the  light  obtained  by  one  physician  with  one 

^  "Die  Behandlung  des  Lupus  mit  Roentgenstrahlen  und  mit  koncentrirten  Licht," 
Beilage  ztir  Centra Ihlatt  filr  Chirurgie,  1898,  No.  26,  pp.  52-63. 

^  "Therapeutische  Verwendung  der  Roentgenstrahlen,"  Fortschritte  a.  d.  Ge/>.  d.  KoetU- 
genslr.,  B.  I,  1 897-1 898. 

'^  Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  B.  I,  1897-1898,  p.  75. 


394 


thp:  roentgen  rays  in  medicine  and  surgery 


apparatus,  as  compared  with  that  obtained  by  another  with  a  different 
apparatus. 

It  seems  advisable  to  call  attention  to  the  inadequacy  of  the  data 
given  by  various  writers,  as  otherwise  it  might  appear  incomprehensible 
that  the  same  results  do  not  follow  when  apparently  the  same  quality 
of  apparatus  is  used. 

Freund  ^  states  that  when  the  X-rays  are  employed  for  treatment 
and  not  for  purposes  of  diagnosis,  with  12  volts  not  more  than  1.5 
amperes  should  be  used ;  that  the  spark-length  of  the  coil  should  not 
exceed  30  centimetres,  and  that  the  interruptions  should  vary  between 
800  to  1000  per  minute.  I  may  say,  on  the  other  hand,  that  I  have 
used  a  current  of  1.5  to  2  amperes  at  220  volts,  and  a  coil  with  a  spark- 
length  of  75  centimetres,  in  treating  lupus,  without  exciting  dermatitis, 
much  less  excoriation  and  gangrene. 

Lupus  Vulgaris 

Illustrative  Cases.  —  The  two  following  cases  were  treated  by  Kiim- 
mell^  and  show  good  results  without  any  harmful  effects  except  for  a 
slight  reaction  in  the  second  case  which  required  an  interruption  in  the 
treatment.  Kiimmell  placed  his  tube  at  first  at  a  distance  of  from  10-6 
centimetres,  but  as  a  very  violent  reaction  appeared  after  a  relatively 
short  time  he  later  increased  this  distance  to  40  centimetres,  diminishing  it 
gradually,  if  no  reaction  appeared,  to  20  centimetres.  The  sittings 
were  never  over  half  an  hour  long,  and  generally  were  one-quarter 
hour  twice  a  day.  He  lays  stress  on  the  importance  of  knowing  exactly 
the  intensity  of  the  hght. 

Case  I.  Mrs.  D.,  twenty-eight  years  old.  Lupus  of  the  nose  for 
ten  years ;  under  medical  treatment  five  years.  The  whole  nose  was 
covered  with  nodules,  ulcerations,  and  scabs,  and  the  nostril  was  partly 
destroyed.  Treatment  with  the  X-rays  was  begun  on  November  28, 
1897,  and  two  sittings  daily  of  one-quarter  hour  each  were  given. 
January  13,  1898,  the  ulcerations  had  cicatrized,  the  scabs  had  fallen 
off,  and  the  nodules  had  disappeared  ;  but  the  nose  was  still  red.  The 
patient  was  then  discharged  from  the  hospital  and  came  to  it  only  for 
treatment.     The  redness  of  the  skin  began  to  abate. 

Case  II.  Mrs.  K.,  fifty-six  years  old.  Tuberculosis.  Lupus  of 
the  nose  for  fifteen  years.     The  end  and  left  side  of  the  nose  as  well  as 

^   IVfiner  Med.  Presse,  No.  31,  1899. 

2  Beilage  zur  Cetiiralblatt  fur  Chirtirgie,  No.  26,  1898,  pp.  52-63. 


THERAPEUTIC    USES   OF   THE   X-RAYS  395 

the  left  side  of  the  cheek  was  infiltrated  and  covered  with  numerous 
nodules  and  ulcerations.  Treatment  with  X-rays  given  ;  slight  reaction  ; 
pause  of  a  few  days  ;  complete  recovery  after  three  months'  treatment ; 
the  traces  of  the  disease  scarcely  to  be  seen. 

Comparison  of  X-Ray  and  Other  Treatment  in  One  Case  reported 
by  Kummell. 

Case  I.  Extensive  lupus  over  the  whole  face,  on  the  forehead,  and 
reaching  down  to  the  right  shoulder.  To  show  the  effect  of  different 
treatments  one  side  was  treated  with  the  rays,  the  other  by  Dr.  Hol- 
lander with  hot  air  cauterization,  and  both  sides  healed  ;  but  on  the 
cauterized  side  of  the  face  the  lupus  nodules  reappeared  and  ectropion 
followed  on  account  of  the  contraction  of  the  scar. 

Kummell  continued  the  treatment  in  his  cases  until  the  scabs  had 
fallen  off,  the  ulcers  were  healed,  and  the  nodules  had  mostly  disap- 
peared. He  considered  his  recoveries  as  only  provisional,  as  the  time 
elapsed  was  too  short  to  speak  of  permanent  results. 

Insulation.  —  Kummell  insulated  some  of  his  patients  by  placing 
them  in  chairs,  under  the  legs  of  which  glass  was  put,  in  order  to 
hasten  treatment  that  was  often  slow  in  its  effects,  but  later  gave  up 
this  procedure  because  of  the  very  quick  and  unaccountably  strong 
reaction  which  often  took  place.  Gocht  insulated  some  of  his  patients 
in  like  manner.     He  mentions  no  ill  effects. 

Mode  of  Healing.  —  The  process  of  healing  in  lupus  cases  was  ob- 
served by  Kummell  to  proceed  in  the  following  way  as  a  rule  :  cleans- 
ing of  the  ulcers ;  cicatrization  ;  drying  up  and  falling  off  of  the  scabs ; 
peeling  of  the  skin  ;  decrease  in  the  size  of  the  nodules ;  disappearance 
of  the  redness ;  formation  of  a  white  scar  without  any  contraction. 
Kummell  thinks  the  essential  point  of  this  method  consists  in  the  fact 
that  the  scar  formed  is  more  like  the  normal  skin  than  can  be  obtained 
with  any  other  method,  and  this  result  outweighs  the  long  duration  of 
the  treatment.  He  also  thinks  that  the  healing  is  the  surer  the  more 
the  injury  to  the  skin  is  avoided. 

Schiff's  ^  experience  as  to  the  process  of  heahng,  after  the  treatment 
of  his  first  two  cases,  is,  like  Kiimmell's,  instructive,  and  gives  a  little 
different  picture  of  what  goes  on  in  the  skin  :  — 

1 .  A  general  phlogistic  reaction  ; 

2.  Specific  reaction  of  the  lupus  tissue  to  the  X-rays,  as  shown  by  the  fact  that  lupus 

nodules  not  visible  before  the  treatment  were  manifest  afterward ; 

1  Archil'  fit r  Dcnit.  it.  Syph.,  B.  42,  1898. 


396     THE    ROENTGEN    RAVS    IN    MEDICINE   AND   SURGERY 

3.  Loosening  and  falling  off  of  nodules,  following  the  exposure  ; 

4.  Subsidence  of  the  swelling  of  the  lymph  glands  in  the  lupus  tract ; 

5.  The  torpid  ulcers  seemed  to  be  changed  into  active  granulations  by  the  X-rays. 

Dermatitis  produced  by  Exposure  to  an  Excited  Vacuum  Tube  in  the 
Lupus  Tract  may  be  slow  in  Healing. —  Albers-Schonberg  ^reports  a  case 
which  shows  how  long  a  time  may  be  necessary  to  heal  a  dermatitis  pro- 
duced by  exposure  to  an  excited  vacuum  tube.  The  left  cheek  only  of 
this  patient  was  treated  by  the  X-rays  sixteen  times  in  two  months. 
After  two  sittings  a  redness  appeared,  which  after  sixteen  sittings  in- 
creased, and  was  followed  by  an  excoriation.  This  dermatitis  showed 
extraordinarily  little  tendency  to  heal,  and  after  130  days  was  not  yet 
well,  but  presented  an  excoriated  spot  2.5  centimetres  long  by  2  centi- 
metres broad. 

Long  Duration  of  Treatment.  —  Albers-Schonberg  reports  a  case  in 
which  the  treatment  with  the  X-rays  was  continued  for  a  period  of  eight 
months,  with  intervals  of  many  weeks.  One  hundred  and  fifty-one 
sittings  in  all  were  given.  He  attributes  the  long  duration  of  treatment 
in  this  case  to  the  fact  that  the  patient  was  one  of  the  first  to  be  treated 
and  the  tubes  used  were  too  weak  and  too  old. 

In  nine  cases  reported  by  him  the  current  was  30  volts  and  4-5 
amperes.  The  tube  was  at  a  distance  of  10-25  centimetres  and  its 
resistance  was  1 5  centimetres. 

Dermatitis  diminished  Susceptibility  of  Skin. — Albers-Schonberg 
noticed  in  his  cases  of  lupus  in  which  dermatitis  occurred  that  after  a 
complete  recovery  from  the  dermatitis  the  skin  on  further  exposure  to 
the  X-rays  was  much  less  susceptible  to  them.  The  reaction  appeared, 
generally  speaking,  more  slowly,  and  was  of  a  milder  form  than  at  first. 
Gassmann  and  Schenkel  observed  this  point  likewise. 

X-Rays  in  Combination  with  Unna's  Salve. — The  following  case 
reported  by  Hahn  and  Albers-Schonberg'^  is  of  interest  as  indicating 
the  effect  of  supplementing  the  X-ray  treatment  with  the  use  of  salve:  — 

Case  I.  B.,  eleven  years  old.  Lupus.  Sixty  sittings  in  five  months. 
Improvement  rapid.  The  spot  least  improved  was  unfavorably  placed 
with  regard  to  the  X-rays,  so  that  it  was  not  exposed  to  so  intense  a 
light  as  the  remainder  of  the  tract.  This  spot  was  treated  with  Unna's 
green  salve  with  good  result.  The  X-rays  were  then  applied  again,  after 
which  the  nodules    healed  quickly.       The   boy  had  no  dermatitis,  not 

1  Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  B.  II,  1898-1899,  p.  27. 

2  Munchener  Med.  Wochenschr.,  March  6,  1900. 


THERAPEUTIC    USES   OF   THE   X-RAYS  397 

even  a  passing  redness  or  sensation  of  pain.  Hahn  and  Albers-Schon- 
berg  attribute  this  good  result  to  the  use  of  the  vaseHne  dressing,  and 
state  in  reply  to  the  objection  that  might  be  made  of  an  individual  idio- 
syncrasy in  this  case,  that  in  all  the  cases  in  which  they  used  vaseline 
the  inclination  to  hyperaemia  and  reaction  was  diminished. 

Dr.  A.  Everett  Smith  ^  has  reported  a  case  which  is  of  interest,  as 
the  desired  result  was  accomplished  so  much  more  quickly  than  in  some 
of  those  already  cited. 

Frank  N.,  about  eighty  years  old.  Lupus  patch  on  face  which 
extended  from  the  left  side  of  nose  over  the  bridge  to  the  right  side 
of  nose,  and  involved  the  inner  canthus  of  right  eye  and  the  inner  third 
of  the  lids,  together  with  the  bulbar  conjunctiva.  There  was  never 
much  pain  ;  it  bled  occasionally,  and  disfigured  him  much.  His  general 
health  and  family  history  were  good. 

Sittings  were  given  him  about  every  fifth  day  for  twenty  minutes  at 
a  time,  the  diseased  surface  being  placed  about  5  centimetres  from  the 
light.  He  received  in  all  twelve  treatments.  No  medicine  whatever 
was  allowed.  He  was  using  applications  of  vaseHne  at  first,  but  that 
was  stopped.  "  Marked  improvement  commenced  after  the  second  treat- 
ment, and  was  not  interrupted  until  the  sore  was  completely  and  entirely 
healed.  After  the  second  treatment  healthy  granulations  appeared,  and 
healing  was  remarkably  speedy.  There  was  no  burning  from  the  light 
or  other  unpleasant  symptoms  complained  of,  except  a  slight  headache 
and  a  decided  '  crawling  sensation  '  in  the  sore  after  the  first  two  treat- 
ments." The  cicatrix  produced  a  slight  ectropion,  but  vision  was  normal. 
All  parts  healed  perfectly,  and  a  healthy  cicatrix  formed. 

Recurrence  of  Lupus.  —  Albers-Schonberg  reports  the  following  cases 
in  which  there  was  a  recurrence  :  — 

Case  I.  Miss  K.,  thirty-six  years  old.  Duration  of  disease  about 
eleven  years  ;  always  under  medical  care. 

Treated  by  X-rays  sixty-eight  times.  The  patient  lived  out  of  town, 
so  that  the  treatment  was  carried  on  at  long  intervals.  The  right  cheek 
was  first  exposed  to  the  rays,  and  excoriation  appeared  after  twenty- 
seven  sittings.  The  dermatitis  healed  quickly.  Soon  after  the  latter 
had  been  cured  the  lupus  again  appeared  on  the  same  cheek,  but  was 
got  rid  of  after  from  five  to  six  sittings.  The  left  cheek  showed  excori- 
ation after  twelve  sittings,  but  healed  quickly.     The  parts  affected  by 

^  "  Lupus  Vulgaris  of  Fifteen  Years'  Standing  successfully  treated  and  cured  by  Exposure 
to  X-Rays,"  Philadelphia  Medual  Journal,  December  I,  1900,  pp.  1058-1059. 


39^     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SUR(iERY 

the  lupus  were  replaced  by  healthy  skin.  The  affection  of  the  mucous 
membrane  of  the  nose  was  much  diminished,  but  not  completely  healed. 
Three  months  afterward  there  was  a  recurrence  in  the  shape  of  seven 
nodules  on  each  cheek  ;  some  ulceration  and  crusts.  The  nodules  dried 
up  after  thirteen  sittings.  This  case  when  last  reported '  had  been  free 
from  anything  suspicious  for  si.x  months. 

Albers-Schonberg  and  Hahn  call  attention  to  the  fact  that  the  recur- 
rence healed  quickly,  and  that  in  the  spots  previously  exposed  to  the 
X-rays  the  nodules  developed  more  slowly  and  less  vigorously.  They 
also  quote  a  case  in  which  the  lupus  appeared  in  a  new  spot  three 
months  after  the  original  lupus  tract  had  been  successfully  treated,  but 
suggest  that  this  fact  speaks  favorably  for  rather  than  against  X-ray 
treatment. 

Case  IT  A.  K.,  boy  thirteen  years  old.  Duration  of  disease  about 
four  years. 

This  patient  was  given  twenty-eight  sittings  with  the  X-rays  during 
three  months.  A  reaction  set  in  after  the  second  sitting,  but  there  was 
no  excoriation.  The  process  of  healing  advanced  by  gradual  drying  up 
of  the  nodules. 

Two  months  and  a  half  later  the  lupus  returned  in  the  nostril  and 
at  the  end  of  the  nose.  The  treatment  with  the  X-rays  was  repeated, 
and  at  the  time  the  case  was  reported  the  patient  had  again  recovered. 

Gassmann  and  Schenkel  report  that  in  two  of  their  cases  the  lupus 
recurred  ;  in  the  first  case,  seven  months  after ;  and  in  the  second,  six 
months  after  the  cessation  of  the  treatment. 

Jutassy^  states  that  nearly  fifty  cases  of  lupus  treated  by  means  of 
the  X-rays  by  Kummell,  Freund,  etc.,  have  been  published,  and  that  of 
the  older  cases  about  fifty  per  cent  have  had  a  recurrence  ;  but  that 
there  are  cases  reported  by  Schiff,  Gocht,  Kummell,  and  Albers-Schon- 
berg, which  were  treated  two  years  ago,  and  have  had  no  recurrence. 
Albers-Schonberg  ^  states  that  cases  of  Kummell  and  Gocht  have  been 
free  from  a  return  since  January,  March,  and  July,  1897,  and  two  of 
his  own  since  January,  1898. 

Susceptibility  of  the  Patient.  —  It  has  been  stated  that  the  suscepti- 
bility of  persons  to  the  action  of  the  X-rays  differs ;  therefore,  the  first 
sittings   must  be   cautiously  given  to   test  the  individual  idiosyncrasy. 

^  Miinchener  Med.  Wochenschr.,  February  27,  1900. 

2  Fortsckritte  a.  d.  Geb.  d.  Roentgenstr.,  1900,  Bd.  Ill,  H.  3,  p.  119. 

3  Ibid.,  1 898- 1 899,  Bd.  II,  p.  24. 


THERAPEUTIC    USF:S   OF   THE    X-RAYS 


)99 


The  practitioner  should  begin  with  "small  doses,"  as  one  observer  puts 
it.  It  seems  to  me  however  that  the  condition  of  the  tube  and  of  the 
apparatus  is  a  stronger  factor  than  the  patient. 

Cumulative  Action  of  the  X-Rays.  — •  The  action  of  the  X-rays,  accord- 
ing to  various  observers,  is  cumulative,  and  therefore  special  care  must 
be  taken  in  using  the  treatment.  Dermatitis  can  be  avoided  if  the  nec- 
essary caution  is  exercised.  Albers-Schonberg  states  that  the  first  sign 
of  a  reaction  is  a  slight  irritation  or  heat ;  if  the  sittings  under  these 
conditions  are  continued,  the  part  where  the  reaction  has  appeared 
reddens ;  the  sittings  should  then  be  stopped  until  the  redness  disap- 
pears, and  there  is  no  longer  heat  or  irritation.  By  means  of  these 
pauses  the  cumulative  action  will  be  avoided,  but  if  the  sittings  are 
continued,  dermatitis,  excoriation,  gangrene,  etc.,  will  follow. 

Method  of  Treatment.  —  The  patient  must  be  protected  from  an 
excited  vacuum  tube  not  only  in  the  immediate  neighborhood  of  the 
diseased  tract,  but  elsewhere,  or  dermatitis  and  loss  of  hair  may  follow. 
Some  practitioners  use  sheets  of  lead,  others,  cardboard  covered  with 
tinfoil,  for  this  purpose. 

Protection  by  Shield.  —  A  shield  is  fastened  over  the  portion  of  the 
body  to  be  treated,  by  means  of  a  strip  of  bandage,  for  instance,  passed 
around  the  body  above  and  below  the  point  where  the  disease  is  located. 
The  shield  should  not  be  held  by  the  patient.  If  the  surface  is  uneven, 
a  piece  of  cork  may  be  slipped  under  the  bandage  when  it  is  necessary 
to  press  the  shield  against  the  skin.  The  shield  is  made  of  cardboard  — 
or,  better,  of  blotting-paper,  which  can  be  adapted  to  uneven  surfaces 
—  covered  with  four  thicknesses  of  tinfoil,  and  extends  at  least  5  centi- 
metres in  every  direction  beyond  the  diseased  tract,  in  order  that  the 
neighborhood  of  the  tract  may  be  protected  from  the  rays.  The 
blotting-paper  and  the  tinfoil  may  be  held  together  by  surgeons'  plaster. 
A  hole  is  cut  in  the  shield  corresponding  in  size  to  the  part  to  be  treated. 
The  tinfoil  should  never  be  allowed  to  come  in  contact  with  the  skin, 
and  the  blotting-paper  should  not  be  allowed  to  get  moist,  as  it  then 
becomes  a  conductor  of  electricity,  and  a  current  passing  through  it 
may  irritate  the  skin  under  it. 

The  shield  may  be  made  in  the  following  way  :  A  hole  is  first  cut 
in  the  blotting-paper  corresponding  in  size,  no  larger,  to  the  part  to  be 
treated  ;  then  the  tinfoil  is  fastened  to  it  by  means  of  the  plaster,  next 
the  foil  is  cut  in  lines  radiating  from  the  centre  of  the  opening  in  the 
blotting-paper  and  these  pointed  pieces  are  folded  back. 


400 


THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 


Mask.  —  For  the  face  I  use  a  mask,  made  of  gauze  and  pressed  into 
the  shape  of  a  face,  such  as  may  be  purchased  at  theatrical  supply 
stores.  This  mask  of  course  does  not  obstruct  the  rays.  I  cover  it 
with  tinfoil  except  over  the  diseased  area,  and  cut  one  or  several  small 
holes  in  the  portion  of  the  mask  lying  over  the  part  to  be  treated,  in 
order  to  recognize  the  size  of  the  area.     It  is  better  not  to  make  this 


Fir,.  218  shows  the  method  of  treating  areas  of  lupus,  or  cancer  of  the  face,  with  the  patient  seated 
in  front  of  the  tube.  The  box  containing  the  vacuum  tube  is  seen  on  the  left.  On  the  front  of  the  box 
is  a  diaphragm  of  sheet  lead,  and  outside  of  it  is  a  thin  sheet  of  aluminum  in  which  there  is  no  open- 
ing, and  which  projects  above  the  front  of  the  box  and  is  grounded;  outside  of  these  two  sheets  is  a 
circular  diaphragm  of  glass.  The  opening  in  the  glass  diaphragm  shown  in  the  cutis  rather  too  large 
for  this  patient.  The  patient  has  on  a  mask  which  is  covered  in  its  lower  portion  with  tinfoil,  and  in 
the  centre  of  the  latter  is  cut  an  opening  somewhat  larger  than  the  area  to  be  treated.  An  opening 
has  also  been  cut  in  the  mask,  somewhat  smaller  than  that  of  the  tinfoil ;  in  order  that  the  tinfoil 
may  not  touch  the  face.  A  mask  painted  with  white  lead  may  be  used  instead  of  the  tinfoil  mask. 
The  head  of  the  patient  is  steadied  by  means  of  a  photographer's  stand,  that  is  shown  on  the  right 
of  the  cut. 

hole  of  the  same  size  as  that  of  the  diseased  tract,  if  this  is  a  large  one. 
because  the  mask,  if  so  cut,  would  not  keep  in  place  as  well.  It  is  held 
on  the  head  by  means  of  a  bandage,  in  the  same  way  as  the  shield 
just  described  or  better  by  an  elastic  with  spring-clips  at  each  end. 

Protection  by  a  Box.  —  The  tube  is  enclosed  in  a  box,  coated  on  the 
inside  with  lead  paint  as  devised  by  Rollins  (see  Chapter  IT),  in  the  side 
of  which  a  circular  opening  is  cut  about  5  centimetres  in  diameter,  and 


THERAPEUTIC    USES   OF   THE    X-RAYS  401 

this  diameter  can  be  made  smaller  when  desired  by  a  diaphragm  of 
heavy  sheet  lead  which  is  covered  with  a  diaphragm  of  plate  glass  ; 
this  acts  as  a  diaphragm  and  also  prevents  the  patient  from  getting  a 
slight  spark  from  the  lead  plate.  By  means  of  diaphragms  of  different 
sizes  the  aperture  through  which  the  X-rays  can  pass  is  increased  or 
diminished  according  to  the  size  of  the  part  to  be  treated,  and  therefore 
the  cone  of  rays  will  only  fall  on  the  diseased  part  and  the  tinfoil  of 
the  shield  immediately  surrounding  it.  As  stated  in  Chapter  II,  the 
diameter  of  the  cone  of  rays  when  it  reaches  the  body  is  broader  than 
at  the  aperture  ;  this  fact  must  be  taken  into  consideration  in  choosing 
the  opening  to  be  used  for  a  given  part.  The  need  of  protecting  other 
parts  of  the  body  than  the  immediate  neighborhood  of  the  diseased  spot 
is  illustrated  by  cases  that  have  been  reported  in  the  medical  journals, 
and  this  box,  with  its  adjustable  diaphragm,  is  a  simple  way  of  obtaining 
the  desired  protection,  and  obviates  the  need  of  many  different  shields 
suited  to  different  parts  of  the  body,  such  as  would  otherwise  be  necessary. 

Apparatus.  —  In  my  office  I  have  used  a  coil;  the  current  was  from 
.5  to  2  amperes  at  220  volts.  The  resistance  of  the  tube  was  from 
I  millimetre  to  about  i  centimetre.  At  the  hospital  I  used  my  large 
static  machine,  described  in  Chapter  II,  and  for  therapeutic  purposes  I 
prefer  it  to  a  coil.  The  patient  was  placed  from  10  to  15  centimetres 
from  the  target. 

As  already  stated,  these  data  as  to  the  apparatus  and  the  distance 
of  the  tube  from  the  patient  are  insufficient  for  purposes  of  comparison, 
and  I  give  them  to  emphasize  the  fact,  for  the  above  current  can  be 
used  without  exciting  dermatitis. 

If  the  tube  is  near,  the  action  is  quicker  and  more  intense,  as  the 
intensity  of  the  light  varies  inversely  as  the  square  of  the  distance. 
New  tubes  of  low  resistance,  that  is  to  say,  from  less  than  a  milH- 
metre  to  about  i  centimetre,  are  thought  to  be  better  for  therapeutic 
purposes. 

Length  and  Frequency  of  Sittings.  —  The  length  and  frequency  of 
the  sittings  must  depend  :  first,  upon  the  resistance  of  the  tube ;  second, 
upon  its  distance  ;  third,  upon  the  power  of  the  exciter  used  ;  and  fourth, 
upon  the  susceptibility  of  the  patient  and  whether  a  delicate  part  of  the- 
skin  is  to  be  treated.  Knowledge  of  the  apparatus  and  experience  and 
judgment  are  necessary  to  use  this  treatment.  Each  case  must  be 
treated  according  to  its  special  needs  and  the  apparatus  employed, 
therefore  only  general  rules  can  be  given.  By  some  practitioners  the 
2  D 


402 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


treatment  in  lupus  is  given  daily  except  for  the  pauses  made  neces- 
sary by  the  condition  of  the  skin.  Albers-Schonberg  suggests  that  on 
the  first  and  second  days  the  sittings  should  not  exceed  ten  minutes,  in 
order  that  the  susceptibility  of  the  patient  may  be  tested.  If  the  skin 
remains  normal,  he  increases  the  sittings  to  half  an  hour,  but  makes  that 


Fig.  2iy.     Lupus.     Before  treatment  by  the  X-rays. 


time  the  maximum.  Freund^  thinks  it  is  wise  to  pause  for  two  or  three 
weeks  after  the  first  two  sittings,  in  order  to  avoid  any  immoderate 
reaction  that  might  arise  from  some  idiosyncrasy  of  the  patient.  He 
advises  that  the  sittings  should  then  be  given  daily  and  that  their  length 
should  be  at  first  five  minutes,  later  ten,  and  eventually  twenty  minutes. 

*   IVit'iit-r  Med.  Presse,  No.  31,  1899. 


THERAPEUTIC    USES   OF   THE    X-RAYS 


403 


My  suggestion  is  that  in  the  beginning  the  sittings  should  not  be  given 
oftener  than  twice  a  week,  because  the  ill  effects,  if  any  are  produced, 
follow  so  slowly,  often  one  or  two  weeks  after  the  exposure ;  and  that 
they  should  not  as  a  rule  exceed  ten  minutes.  If  there  is  the  slightest 
indication  of  irritation  the  sittings  should  be  suspended.       The  recovery 


Fig.  220.     Lupus.    After  treatment  by  the  X-rays. 

is  not  hastened  by  pushing  the  treatment  too  energetically,  for  if  a  der- 
matitis is  produced  the  sittings  must  be  temporarily  abandoned.  My 
experience  is  that  it  is  quite  possible  to  carry  out  the  treatment  suc- 
cessfully without  causing  any  inconvenience,  and  certainly  no  severe 
irritation. 


404     THE    ROKNT(;i;N"    RAVS    in    MKDICIXK    AND   SURGERY 

The  two  preceding  cuts  are  taken  from  photographs  of  a  patient 
treated  by  me  with  the  X-rays  :  one  was  made  before  treatment  and 
the  other  after. 

The  two  following  cuts  (see  Figs.  221  and  222)  indicate  the  condition 
of  a  young  woman,  suffering  with  lupus,  at  the  beginning  of  treatment 
and  after  improvement  was  well  begun.  A  final  cut  after  still  further 
improvement  had  taken  place  cannot  be  given  as  the  patient  went  away 
so  that  I  could  not  get  a  photograph. 


Fl('..  221.     Lupus  vulgaris  before  tnatnient. 

In  this  case  the  patient  at  first  had  much  pain,  the  face  was  swelled 
and  the  surface  was  moistened  in  parts  by  a  constant  discharge  of  pus 
or  serum.  During  the  course  of  the  treatment  the  pain  and  swelling 
subsided  and  the  affected  area  became  dry  and  painless. 

Lupus  Erythematosus 

Schiff  1  reports  a  case  of  lupus  erythematosus  which  he  treated  suc- 
cessfully with  the  X-rays. 

The  patient  was  a  \voman,  and  had  suffered  from  the  disease  for 
seven   years.     In  July.    1898,  when  treatment  was  begun,  the  process 

1  Fortschritte  a.  </.  Geb.  d.  Koentgetistr.,  Bd.  II,  pp.  135-137. 


THKRAPEUTIC    USES   OF   THE    X-RAVS 


405 


had    affected    both  cheeks,    ran    up    on  the    nose,    and   also    appeared 
between  the  eyebrows  and  in  one  ear. 

The  left  cheek  only  was  treated  by  the  rays  ;  the  right  cheek  was 
left  untouched  as  a  control  and  for  the  purpose  of  comparison.  On 
September  5  treatment  was  stopped  and  the  condition  of  the  face  was 
as  follows :  The  infiltrations  on  the  left  cheek  had  disappeared  ;  the 
skin,  except  for  some  pigmentation  which  was  gradually  disappearing, 
was  smooth  and  nearly  approached  the  normal.     The  side  of  the  face 


Fu;.  222.     Lupus  vulgaris  after  partial  trcatiiiL-nt. 


that  had  not  been  exposed  to  the  action  of  the  rays  remained  in  its 
original  condition. 

As  a  rule,  during  the  treatment,  new  vacuum  tubes  were  used  which 
gave  out  a  very  intense  light.  The  tube  was  about  10  centimetres  dis- 
tant from  the  cheek  and  each  sitting  lasted  on  an  average  from  ten  to 
fifteen  minutes. 

Jutassy  ^  reports  the  following  case  :  — 

Case  I.  Lupus  erythematodes  nasi  et  faciei.  Man,  twenty-eight 
years  old.     Duration  of  disease  8  years  ;   had  been  treated  without  result 

^  fortschritfe  a.d.  Geb.  d.  RoeutgensO.,  Bd.  Ill,  H.  3,  p.  120. 


4o6      THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

and  the  disease  spread  after  the  use  of  Paquelin's  cautery,  and  the 
lupus  was  disseminated.  This  case  was  treated  by  the  X-rays  from 
October  4  to  October  10,  1898.  The  sittings,  amounting  in  all  to  5.] 
hours,  were  arranged  in  such  a  way  that  the  lesion  on  the  face,  which 
was  in  the  form  of  a  butterfly,  had  longer  treatments  than  the  lesion  on 
the  bridge  of  the  nose.  In  the  beginning  of  November  the  crusts 
came  off  in  large  thick  laminae,  but  a  small  strip  under  the  eye-lids  and 
on  the  bridge  of  the  nose,  that  had  been  covered  by  the  lead  mask, 
remained.  The  patient  was  again  exposed  to  the  rays  from  the  14th 
to  the  29th  of  November  —  six  sittings,  in  all  3  hours  —  so  that  the 
outer  rays  fell  on  the  spots  that  were  already  free.  The  remaining 
crusts  then  came  off,  and  since  that  time,  nearly  ten  months,  the  face 
has  been  for  the  most  part  free.  A  recurrence  took  place  in  March, 
1899,  on  the  bridge  of  the  nose  and  on  the  right  half  of  the  face  in  some 
places,  of  the  size  of  a  bean,  but  did  not  spread  further.  Jutassy  states 
that  the  present  results  justify  the  prognosis  that  the  healing  obtained 
by  the  employment  of  this  new  therapeutic  remedy  will  be  radical. 

Lupus  simulating  Syphilis 

The  following  cases  are  of  interest  as  showing  the  non-effect  of  the 
X-rays  in  these  cases  :  — 

Case  I.  Kummell  reports  the  case  of  a  boy  suffering  from  a 
disease  in  which  the  diagnosis  was  lupus.  He  was  given  X-ray  treat- 
ment, but  as  he  did  not  improve  the  sittings  were  stopped.  The  disease 
proved  to  be  syphilis,  and  under  specific  treatment  the  boy  recovered. 

Case  II.  Gocht  reports  the  case  of  a  man  thirty-nine  years  old  who 
had  had  syphilis  six  years  previously.  Increasing  redness  of  the  nose 
during  four  months.  Treated  with  the  X-rays  for  more  than  a  month 
without  result.  It  was  probably  not  a  case  of  lupus  vulgaris,  but  one  of 
constitutional  syphilitic  affection. 

Hahn  and  Albers-Schonberg  ^  cite  the  following  case  as  one  in 
which  the  X-rays  decided  the  differential  diagnosis. 

Case  III.  Mr.  P.  There  was  a  large  ulcer  on  the  left  side  of  the 
nose,  which  was  declared  by  a  pathological  anatomist  and  by  a  special- 
ist to  be  of  tuberculous  origin.  Hahn  and  Albers-Schonberg  hesitated 
as  to  the  diagnosis  of  lupus,  although  syphilitic  infection  was  denied. 
By  request  of  the  patient's  physician  X-ray  treatment  was  given,  but 

^  Mimchener  Med.  Wochenschr.,  March  13,  1900. 


therapp:utic  uses  of  the  x-rays  407 

no  change  was  produced  by  eight  sittings.  The  physician  then  gave 
specific  treatment  and  the  ulcer  was  completely  cured  within  fourteen 
-days.  The  patient  then  remembered  an  infection  of  some  years  previous. 
Concentrated  Sunlight  and  Electric  Arc  Light.  —  Finsen  has  used 
concentrated  sunlight  and  electric  arc  light  in  the  treatment  of  lupus. 
Kiimmell  thinks  the  disadvantage  of  this  method  as  compared  with  the 
X-rays  is  the  fact  that  with  the  first  two  only  a  small  part  can  be 
treated  at  one  time,  whereas  with  the  X-rays  the  whole  tract  can  be 
treated  at  once.  Kiimmell  also  thinks  it  might  be  practical  eventually 
to  combine  the  two  methods ;  that  the  large  lupus  tracts  might  be 
treated  with  the  X-rays,  and  that  when  single  nodules  only  remain  the 
concentrated  light  of  Finsen's  apparatus  might  be  used.  Freund  like- 
wise states  that  Finsen's  method  takes  a  great  deal  of  time,  particu- 
larly with  persons  who  have  a  strongly  pigmented  skin,  because  the 
pigment  hinders  the  action  of  the  light  in  the  deeper  layers. 

Eczema 

Hahn  ^  reports  two  cases  of  eczema  treated  by  the  use  of  the 
X-rays  :  — 

Case  I.  Mrs.  W.  had  suffered  for  four  years  from  chronic  eczema 
in  both  legs,  which  had  resisted  all  possible  therapeutic  remedies.  The 
spot  on  the  right  leg  was  as  large  as  the  palm  of  the  hand.  The  eczema 
was  cured  by  subjecting  the  diseased  parts  to  the  action  of  the  X-rays 
twelve  times.  The  treatment  was  given  daily,  with  the  exception  of  Sun- 
days and  of  those  days  when  the  patient  was  prevented  from  coming. 
It  lasted  from  twenty  to  twenty-five  minutes,  and  the  tube  was  placed 
at  a  distance  of  about  30  to  40  centimetres  from  the  patient. 

Later  report  :  ^  Nine  months  afterward,  slight  recurrence  on  one 
leg,  but  the  other  remained  well. 

Case  II.  Mrs.  W.  had  had  eczema  for  two  years  in  both  legs. 
On  the  outside  of  the  right  leg  there  was  an  area  about  12  centimetres 
long  by  6-7  centimetres  broad,  and  on  both  sides  of  the  left  leg  there 
was  a  patch  the  size  of  the  palm  of  the  hand.  In  this  case  also  all 
therapeutic  measures  had  been  tried  without  result.  The  right  leg  was 
subjected  to  the  action  of  the  X-rays  four  times,  and  then  a  reaction 
took  place,  which   showed  itself  as  a  redness  on  the  spot  itself  and  in 

1  "  Durch  Roentgenstrahlen  geheiltes  chronisches  Ekzem,"  Fortschritte  a.  d.  Geh.  d. 
Roentgenstr.,  Bd   II,  pp.  16-18. 

2  Muncheiier  Med.  Wochoischr.,  March  6,  1900. 


4o8     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

the  immediate  neighborhood ;  but  this  redness  yielded  in  three  days  on 
the  appHcation  of  bandages  wet  with  lead  water.  The  X-rays  were  then 
again  applied  to  the  right  and  also  to  the  left  leg,  and  the  eczema  was 
cured.  Each  individual  treatment  in  this  case  was  of  the  same  duration 
as  in  Case  I,  and  the  tube  was  at  the  same  distance  from  the  patient. 

Later  report.^  Slight  recurrence  six  months  afterward  on  the  left 
leg,  which  yielded  to  treatment  with  salve. 

Hahn  also  gives  a  case  of  chronic  eczema  treated  by  Albers-Schon- 
berg  with  the  X-rays,  which  finally  involved  the  whole  back  of  the  hand 
and  which  had  been  treated  without  result.  The  treatment  with  the 
X-rays  began  on  February  9,  and  was  given  daily  for  half  an  hour.  On 
February  1 1  there  was  a  slight  reaction.  On  March  28  the  hand  was 
completely  well.  On  April  19  a  few  eczematous  pustules  the  size  of 
the  head  of  a  pin  appeared  on  the  back  of  the  hand,  which  made  the 
diagnosis  of  chronic  eczema  certain. 

The  two  following  cases  of  Albers-Schonberg  increase  the  evidence 
already  adduced  in  this  direction  as  to  the  beneficial  effect  of  the  X-rays 
in  cases  of  eczema  :  — 

C.^SE  I.  Chronic  impetiginous  eczema  of  the  head.  Boy  five  years 
old  ;  had  been  treated  for  four  years  without  result.  The  whole  face, 
the  head  where  the  hair  grew,  and  the  neck  were  changed  into  a  surface 
covered  with  scabs  and  crusts  with  exudation  ;  the  face  was  bloated,  the 
eyelids  swollen.  To  demonstrate  the  action  of  the  X-rays  the  face,  head, 
and  neck  were  covered  with  a  tinfoil  mask,  out  of  which  was  cut  an 
oval  hole  9x5  centimetres  in  size,  and  a  portion  of  the  cheek  only  was 
thus  left  exposed.  After  a  treatment  of  about  twenty  minutes  the  part  of 
the  cheek  exposed  presented  a  changed  appearance ;  it  was  dry  and 
remained  dry.  After  a  few  more  sittings  a  lively  peeling  of  the  epi- 
dermis set  in  on  the  part  treated.  The  rest  of  the  face  and  head  and 
neck  were  then  systematically  treated,  with  equally  quick  and  good 
results.  The  exudation  ceased  and  no  more  scabs  formed.  The  dry 
skin  began  to  peel  off,  islands  of  normal  skin  arose  and  increased  in  size. 
After  thirty  treatments  the  child  showed  traces  only  of  the  eczema. 
The  bloating  of  the  face  had  completely  disappeared,  and  the  general 
condition  was  good.  The  recovery,  when  the  case  was  reported,  was 
going  on  well. 

I  find  a  case  given  by  Albers-Schonberg  and  Hahn  in  a  later  article,^ 

1  Mihtchener  Med.  IVocIieiischr.,  March  6,  1900. 

2  Ibid. 


THERAPEUTIC    USES   OF   THE   X-RAYS  409 

which  seems  to  be  a  further  report  of  this  same  case.  After  a  month 
the  eczema  appeared  on  the  throat,  but  the  head  and  face  remained 
almost  entirely  well.  The  sittings  were  then  renewed,  but  only  a 
transient  improvement  took  place.  Later,  the  boy  had  a  treatment  of 
sulphur  baths  and  vaseHne,  and  was  completely  cured  ;  after  five  months 
the  eczema  returned  again,  but  was  again  (when  reported)  improving 
under  treatment. 

Case  II.  Child.  Extensive  impetiginous  eczema  of  the  face  and 
head.     Duration  of  disease  six  weeks. 

Ten  to  twelve  X-ray  sittings  were  given  and  no  reaction  was  pro- 
duced. The  face  healed  quicker  than  the  head  under  the  hair.  The 
hair  came  out,  but  in  about  a  month  had  grown  again.  Child  completely 
well  a  year  later. 

The  prominent  characteristic  during  the  healing  process  of  these 
two  cases  was  the  extraordinary  quickness  with  which  the  X-rays  worked. 
Albers-Schonberg  characterizes  the  effect  as  follows:  (i)  cessation  of 
the  exudation  ;  (2)  drying  up  of  the  skin  ;  (3)  peeling. 

Jutassy  1  reports  the  following  case,  which  is  instructive  as  a  warning, 
because  the  treatment  was  continued  longer  than  proved  to  be  neces- 
sary, and  a  dermatitis  was  set  up  :  — 

Eczema  chronicum  manus.  Man  twenty-nine  years  old.  On  the 
back  of  both  his  hands.  Disease  of  seven  years'  duration.  Treated 
medically  without  result.  X-ray  treatment  given  from  July  25  to  August 
3,  1898,  eight  sittings,  the  whole  time  amounting  in  all  to  two  and  a 
half  hours,  after  which  upon  the  intact  skin  reddish  brown  erythema 
appeared,  and  the  lesions  arising  from  the  eczema  came  off.  On  the 
metacarpo-phalangeal  joint  of  the  hand  only,  a  large  crust  the  size  of 
the  palm  of  a  child's  hand  remained,  therefore  this  portion  was  X-rayed 
again  on  August  8.  It  proved,  however,  to  be  superfluous,  for  a 
purulent  dermatitis  set  in,  and  while  the  skin  of  the  left  hand  and  the 
other  part  of  the  right  hand  got  well  in  a  few  days,  the  complication 
took  about  a  month  to  heal,  and  a  smooth  white  scar  was  left.  Since 
then,  thirteen  months,  there  has  been  no  recurrence. 

The  most  striking  case  of  the  usefulness  of  the  X-rays  in  the  treat- 
ment of  acute  eczema  which  I  have  had,  is  the  following:  — 

Case  I.  B.  J.  A  man  fifty  years  old,  who  had  suffered  from  this 
disease  every  winter  for  several  years  past,  and  who  formerly  required 
to  be  treated  some  weeks  or  months  before  he  obtained  reHef.     This 

^  Fortschritte  a.  d.  Geb.  d.  Roentgenslr.,  Bd.  Ill,  H.  3,  p    120. 


4IO    THE    ROENTGEN    RAVS   IN    MEDICINE   AND   SURGERY 

year,  on  the  19th  of  the  month,  he  came  to  see  me  and  stated  that  the 
night  before  he  had  had  intense  itching  and  redness  of  the  skin  on  the 
outer  part  of  the  left  upper  arm,  and  that  he  had  waked  in  the  night  to 
find  his  night-dress  saturated  with  exudation  from  this  area.  When  I 
saw  him  there  was  a  red  area  15  centimetres  long  and  10  centimetres 
wide,  which  was  rough  but  not  moist.  The  intense  itching  of  this  area 
was  extremely  hard  to  bear. 

I  made  a  single  exposure  of  the  diseased  tract  to  the  X-rays,  with 
the  exception  of  a  small  portion  that  was  excluded  as  a  control,  at  three 
o'clock,  P.M.,  for  ten  minutes,  the  target  of  the  vacuum  tube  being  at  a 
distance  of  10  centimetres  from  the  skin.  In  the  evening  the  itching  had 
decreased,  and  on  the  following  morning  there  was  no  itching  and  abso- 
lutely no  discomfort  over  the  part  which  had  been  exposed  to  the  X-rays. 

On  the  2 1  St  of  the  month,  forty-eight  hours  after  the  first  exposure 
to  the  X-rays,  the  skin  was  still  rough,  but  there  was  no  pain  and  no 
itching.  The  small  portion  of  the  eczematous  area  which  had  purposely 
not  been  exposed  to  the  rays  was,  however,  still  red,  swollen,  and  itch- 
ing, and  this  M'as  now  subjected  to  the  X-rays  for  eight  minutes  ;  like- 
wise a  reddened  area  on  the  inside  of  the  left  arm,  which  itched 
somewhat,  for  six  minutes. 

On  the  23rd  of  the  month  there  was  a  slight  redness  and  irritation 
on  the  inner  side  of  the  left  arm,  and  this  tract  was,  therefore,  exposed 
to  the  X-rays  for  ten  minutes.  On  the  26th  of  the  month  the  patient 
returned  to  state  to  me  that  he  had  been  perfectly  well  since  the  treat- 
ment, and  there  had  not  been  the  slightest  itching.  The  area  first 
affected,  on  the  outer  part  of  the  arm,  which  was  1 5  centimetres  long 
and  10  centimetres  wide,  was  still  rough,  but  gave  him  no  discomfort 
whatsoever. 

Case  II.  X.  Y.  had  chronic  eczema  of  the  back,  neck,  and  arms, 
with  much  itching  in  some  portions,  especially  about  the  elbows.  He 
had  been  treated  six  weeks  by  the  usual  method.  I  tried  to  relieve  him 
by  means  of  the  X-rays.  After  the  first  exposure  the  patient  thought 
the  itching  was  much  diminished,  but  it  returned  on  the  second  day,  and 
further  daily  exposures  to  the  X-rays  for  several  days  did  not  give  him 
any  relief.  It  is  not  improbable  that,  if  I  had  then  known  better  how 
to  use  the  X-rays  in  this  disease,  I  might  have  been  able  to  help  him. 
Possibly  the  parts  treated  by  the  X-rays  healed  subsequently  under  oint- 
ments more  rapidly  than  they  might  otherwise  have  done  ;  but  I  am  not 
satisfied  that  the  X-rays  were  of  any  advantage  to  this  patient. 


THERAPEUTIC    USES   OF   THE   X-RAYS  41I 

Hahn  and  Albers-Schonberg  ^  draw  the  following  conclusions  from 
fourteen  cases  of  eczema  :  — 

In  eczema  with  exudation,  the  latter  dried  up  after  from  one  to  four 
sittings,  and  remained  dry.  In  eczema  with  itching,  the  latter  ceased 
often  permanently  after  one  sitting.  In  dry  eczema  the  influence  of 
the  X-rays  was  also  favorable  ;  on  an  average,  after  the  fourth  sitting  a 
striking  change  appeared ;  the  spots  that  had  looked  as  if  they  were 
dead  took  on  a  fresher  appearance  ;  the  surface  became  smooth,  though 
somewhat  red,  and  the  crusts  did  not  form  again. 

Small  tracts  of  eczema  were  cured  after  a  few  sittings  and  "did  not 
need  further  treatment ;  if  the  eczema  was  more  extensive  a  longer 
course  of  treatment  was  necessary  ;  but  in  all  cases,  even  the  most 
obstinate,  they  obtained  a  good  result.  In  cases  of  recurrence  the  X- 
rays  were  not  so  effective ;  more  sittings  were  necessary  ;  the  disease 
did  not  react  so  promptly.  On  the  other  hand,  medical  treatment, 
which  had  been  absolutely  useless  before  the  employment  of  the  X-rays, 
produced  its  proper  results  after  the  sittings  and  completed  the  cure  that 
had  been  initiated  by  the  rays.     The  following  case  is  illustrative  :  — 

Case  I.  Miss  M.  Eczema  with  itching  and  fissures  on  both  hands. 
Duration  of  disease  one  year ;  constantly  under  treatment. 

Three  sittings  with  the  X-rays.  After  the  first  sitting  of  twenty 
minutes'  duration  the  itching  disappeared.  Six  months  later  a  recur- 
rence. The  itching  was  again  stopped  after  one  treatment.  Great  im- 
provement in  the  disease  after  the  tenth  treatment.  For  reasons  per- 
sonal to  the  patient  the  X-ray  sittings  were  abandoned,  and  salve  was 
applied  with  good  result,  although  before  the  use  of  the  X-rays  it  had 
been  employed  without  effect. 

The  conclusions  arrived  at  by  Hahn  and  Albers-Schonberg  ^  after  the 
treatment  of  twenty  cases  of  lupus,  one  of  favus,  and  two  of  psoriasis 
vulgaris,  in  addition  to  the  fourteen  cases  of  eczema  mentioned  above, 
are  also  of  special  interest :  — 

1.  The  X-rays  work  surely  and  favorably  in  lupus  and  other  skin  diseases. 

2.  They  cure    absolutely  the  eczema  which  accompanies    lupus,  and   the    thickening 

resembling  elephantiasis  arising  from  the  same,  and  therefore  are  adapted  to  the 
treatment  of  surfaces  and  deeper  parts. 

3.  Recurrences  are  not  excluded  by  this  method  any  more  than  by  any  other  method. 

4.  The  X-ray  treatment  does  not  exclude  other  methods,  but  rather  supplements  them, 

or  may  be  combined  with  them. 

1  Mimchener  Med.    Wochenschr.,  March  6  and  13,  1900. 

2  Ibid.,  March  13,  1900. 


412     THE    ROHNHiEN    RAVS   IN    MEDICINE    AND    SURGERY 

5.  What  is  true  ot  lupus  is  also  true  of   eczema  and  of  other  skin  diseases,   which, 

however,  need  further  study. 

6.  Bv  appropriate  treatment  and  technical  skill,  dermatitis,  excoriation,  gangrene,  etc., 

can  be  avoided. 

N^vus  Flammeus  or  Vasculosus 

The  following  case,  reported  by  Jutassy,^  is  of  such  interest  that  I 
give  it  in  some  detail :  — 

J.  E.,  twenty-two  years  old ;  cabinet-maker  ;  congenital  teleangiec- 
tasia or  naevus  vasculosus  or  flammeus  faciei. 

The  process  affected  almost  the  whole  right  half  of  the  face.  The 
teleangiectasia  did  not  rise  above  the  level  of  the  skin  on  the  forehead, 
but  on  the  cheek  and  nose  livid  growths  from  the  size  of  hempseed  to 
that  of  beans  could  be  seen,  so  that  the  teleangiectasia  was  combined 
with  angioma. 

The  color  varied  from  the  color  of  cinnabar  to  dark  purple  ;  the 
edges  and  the  whole  of  the  forehead  that  was  involved  was  lighter  than 
the  centre  of  the  nrevus  ;  the  nose  and  the  skin  about  the  eye  appeared 
particularly  livid.  The  patient  was  of  middle  height,  well  developed, 
and  healthy.  The  hair  of  his  beard  and  mustache  was  weak  and  strik- 
ingly scanty  on  the  affected  parts. 

The  treatment  was  begun  in  October,  1897,  but  only  a  small  part 
was  treated  at  first  as  an  experiment.  The  head  and  neck  were  pro- 
tected by  a  thick  piece  of  lead  in  which  a  hole  3  by  4  centimetres 
was  cut.  Thus  not  only  a  portion  of  the  naevus  was  exposed,  but  also 
a  healthy  piece  of  skin  3  to  4  millimetres  broad,  as  a  control  experi- 
ment. 

From  October  6  to  12,  1897,  the  patient  was  exposed  in  all  four  and 
a  half  hours  to  the  X-rays,  in  eight  sittings,  and  then  a  slight  hyper- 
aemia  showed  itself  on  the  healthy  skin,  which  in  the  course  of  ten  days 
became  dark  brown  in  color  and  the  naevus  became  dark  red.     At  the  i| 
end  of  October  the  epidermis  came  off  in  small  scales,  and  by  the  use  i 
of    oxide  of    zinc  salve    the  slight    dermatitis  was    healed    entirely  by  '; 
November  10. 

The  naevus  part  of  the  skin  that  had  been  subjected  to  the  X-rays  , 
was  essentially  paler,  and  showed  a  marked  contrast  between  its  color  (I 
and  that  of  the  naevus  to  which  the  X-rays  had  not  been  applied,  so  (! 
that  the  experiment  was  considered  a  success. 


1  FortschrUte  a.  d.  Geh.  d.  Roentgeuslr.,  B.  II,  1898,  pp.  213-216. 


J 


THERAPEUTIC    USES   OF   THE    X-RAYS  413 

Jutassy  then  produced  a  more  severe  dermatitis.  The  X-rays  were 
applied  from  November  20  to  30,  and  to  prevent  the  hair  of  the  head 
,and  beard,  and  the  eyebrows  and  eyelashes,  from  falling  out,  a  lead 
imask  was  put  on  which  left  the  cheek,  nose,  and  forehead  uncovered. 
I  The  naevus  was  so  exposed  to  the  rays  in  eleven  sittings  that  the  centre 
!of  the  light  alternately  touched  the  cheek,  then  the  nose,  and  lastly  the 
[forehead  ;  so  that  the  cheek  and  forehead  were  subjected  to  intense 
:light  for  from  five  to  ten  hours,  and  the  nose  four  hours;  altogether 
the  face  was  exposed  to  the  light  fourteen  hours,  until  the  normal  por- 
tion of  the  face  that  was  left  unprotected  by  the  lead,  for  a  control, 
showed  an  erythema.  The  dermatitis  developed  until  December  10, 
and  gave  all  the  characteristic  features  of  an  inflammation.  The  patient 
complained  of  trouble  in  the  bones  of  his  face  at  the  articulation  of  his 
jaw.  In  the  next  two  weeks  an  eczematous  excoriation  was  visible, 
which  later  passed  into  a  pustular  eruption.  The  epidermis  largely 
scaled  off  and  the  corium  lay  exposed. 

On  December  25,  the  patient  went  to  St.  Roch's  Hospital,  where 
he  was  treated  first  daily,  then  every  two  days,  and  later,  every  three 
days,  with  boric-vaseline.  The  new  skin  formed  tolerably  quickly 
toward  the  centre.  On  January  10,  1898,  the  skin  of  the  nose  was 
completely  healed.  At  the  beginning  of  February,  1898,  the  inflamma- 
tory process  had  entirely  disappeared.  The  naevus,  except  in  the  pro- 
tected parts,  that  is,  in  the  neighborhood  of  the  eye,  the  upper  lip,  and 
the  skin  of  the  head  under  the  hair,  had  disappeared  ;  there  was  no 
trace  of  angioma.  Over  the  part  that  had  been  exposed  to  the  X-rays 
was  a  soft  smooth  scar,  rose-red  in  places,  but  which  scarcely  differed 
from  the  normal  skin.  On  the  edge,  only,  was  the  yellowish  brown 
hyperpigmentation  marked.  Where  the  head  and  beard  were  unpro- 
tected by  the  lead  a  little  hair  fell  out. 

Nearly  a  year  and  a  half  after  the  treatment  was  given  the  skin  of 
the  forehead  and  nose  could  scarcely  be  distinguished  from  the  normal 
skin.  The  cheek  where  the  livid  spots  had  been  showed  still  a  rose-red 
color.  The  hyperpigmentation  was  essentially  diminished  by  medical 
treatment,  but  did  not  entirely  disappear,  therefore  Jutassy  thinks  the 
pigment  was  probably  not  in  the  outer  skin,  but  in  the  upper  layer  of 
the  cutis.  The  new  skin  was  thin  and  susceptible  to  changes  in  the 
temperature.  In  winter  it  had  a  deeper  shade  of  rose-red,  whereas  in 
warm  weather  it  almost  disappeared.  Two  photographs  of  the  patient 
are  given,  one  before  and  one  after  treatment. 


414     iHE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Sycosis   and    Favus 

Freund  and  Schiff,  ^  in  treating  sycosis  and  favus  by  the  X-rays,  were 
guided  by  the  idea  that  by  removing  the  hair,  which  they  looked  upon 
as  a  foreign  body,  they  would  eUminate  every  exciting  cause  of  inflam- 
mation in  the  outer  folHcular  tissues,  the  cutis,  and  the  papillae.  And 
in  fact  after  the  removal  of  the  hair  they  saw  no  new  pustules  form  in 
the  cases  of  sycosis ;  the  secretion  and  crust  formation  ceased  com- 
pletely. They  also  noticed  that,  before  the  removal  of  the  hair,  the 
appearances  due  to  acute  inflammation  were  much  less  prominent,  and 
the  most  striking  inflammatory  infiltrations  in  the  neighborhood  of  the 
parts  of  the  beard  that  were  affected  grew  more  level  with  the  surface 
and  disappeared.  At  this  stage  the  hair  that  was  pulled  out  showed 
dry  roots  without  any  bulbous  swelling,  whereas  before  the  roots  were 
surrounded  by  a  glossy  infiltrated  sheath.  At  the  same  time  the  sub- 
jective troubles  of  tension  and  heat,  from  which  the  patient  had  suffered, 
yielded. 

When  treating  the  favus  they  proceeded  very  energetically.  All 
the  hair  on  the  head,  whether  affected  apparently  with  favus  or  not, 
was  exposed  to  the  X-rays,  and  the  treatment  was  not  stopped  until  the 
skull  was  completely  deprived  of  hair.  This  was  done  with  the  idea  of 
destroying  any  hidden  parasites  by  which,  eventually,  the  neighboring 
parts  might  be  affected.  The  repeated  treatment  was  not  intended  to 
prevent  the  hair  of  the  head,  or  of  the  beard  from  growing  again,  and 
it  did  not. 

Freund  and  Schiff  state  that  with  the  methods  of  treatment  carried 
on  by  them  no  dermatitis  occurred.  As  soon  as  any  redness  appeared 
which  deviated  in  the  slightest  degree  from  the  redness  due  to  the 
hypersemia  already  present,  the  treatment  was  stopped.  After  from 
seven  to  eleven  sittings  the  hair  was  loosened  and  fell  out,  or  was  easily 
pulled  out  by  the  fingers.  The  redness,  together  with  all  other  indica- 
tions of  disease,  disappeared  in  the  course  of  the  next  ten  to  twelve 
days. 

The  method  was  as  follows :  The  apparatus  used  was  a  Ruhmkorff 
coil  with  a  spark-length  of  30  centimetres.  It  was  excited  by  means  of 
six  storage  cells  (12  volts).  The  resistance  of  the  tube  never  exceeded 
10  to  15  centimetres.     The  interruptions  did  not  follow  so  quickly  upon 

1"  Weitere  Anwendungsgebiete  der  Radiotherapie,"  Fortschrilte  a.  J.  Geh.  d.  Roentgenstr., 
Bd.  Ill,  H.  3,  pp.  109-110. 


THEIL^PEUTIC    USES   OF   THE   X-RAYS  415 

one  another  but  that  a  flickering  of  the  light  could  be  plainly  seen. 
The  tube  at  first  was  at  a  distance  of  15  centimetres  from  the  part 
treated,  but  the  distance  was  gradually  reduced  to  5  centimetres.  The 
sittings,  which  at  first  lasted  only  five  minutes,  were  increased  to  fifteen 
minutes.  The  healthy  skin  in  the  neighborhood  of  the  parts  treated  was 
protected  by  sheets  of  pasteboard  covered  with  lead  .5  millimetre  thick. 
Case  1.  F.  S.,  twenty-six  years  old.  Sycosis  of  the  beard.  Dura- 
tion of  disease  four  years.  On  both  cheeks  where  the  hair  was  grow- 
ing were  numerous  nodules  and  pustules,  pierced  by  a  hair  and  often 
surrounded  by  a  scab.  The  roots  of  the  hair  were  swelled  with  puru- 
lent matter.  The  upper  lip  was  free  from  disease.  The  treatment  was 
begun  on  April  18,  1899.  On  April  25  the  hair  was  loosened  and  came 
out  when  slightly  pulled.  Slight  hyperasmia.  After  another  week  all 
reaction  disappeared.  The  spots  that  had  been  affected  by  sycosis 
iwere  smooth  and  white. 

1  Case  II.  J.  H.,  eczema  chronicum  barbae,  blepharitis  bilateralis. 
Duration  of  disease  over  fifteen  months.  When  the  crusts  came  off 
there  were  diffuse  moist  areas. 

I  Treatment  was  begun  on  the  left  side,  May  18,  1899,  and  after  eleven 
i sittings  the  hair  fell  out.  After  five  sittings  the  exudation  had  completely 
I  ceased.  The  blepharitis  disappeared  at  the  same  time  as  the  sycosis. 
|A  slight  erythema  appeared  and  disappeared  after  six  days.  June  7 
treatment  was  begun  on  the  right  side,  and  was  brought  to  a  close  on 
June  19.  October  2  the  patient  had  a  thick,  full  black  beard  again, 
'which  was  in  a  perfectly  healthy  condition. 

i  Case  III.  J.  H.,  twenty-eight  years  old.  Sycosis  of  the  upper 
I  lip  and  chin.  Duration  of  disease  six  months.  A  photograph  of  the 
[patient  is  given  before  treatment,  which  was  begun  on  February  28, 
.'1899,  another  after  the  conclusion  of  the  treatment  on  March  17,  1899. 
jln  the  second  picture  the  mustache  was  gone,  and  the  face  looked  smooth. 
•  On  September  4,  the  mustache  had  grown  out  again.  On  the  chin 
fwere  isolated  inflamed  follicles,  but  after  three  sittings  these  were  again 
'normal. 

I  Case  IV.  J.  H.,  ten-year-old  schoolboy.  Favus  scutularis  capil- 
jlitii  of  seven  years'  duration.  On  April  8,  1899,  treatment  was  begun 
!on  the  left  half  of  the  back  part  of  the  head.  The  hair  fell  out  April 
|22.  Then  treatment  was  begun  on  the  skull  in  the  region  of  the  fore- 
Ihead,  and  was  brought  to  an  end  on  May  5.  At  last  the  right  half  of 
•the  back  of  the  head  was  treated.     The  whole  treatment  ended  May  26. 


41 6     THK    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

After  the  treatment  was  over,  the  use  of  carbolanohn  salve  was  pre- 
scribed for  fourteen  days.  October  2  the  skin  on  the  head  was  per- 
fectly healthy  and  the  hair  that  had  come  out  had  been  replaced  by  a 
new  o^rowth. 

Sycosis  Non-Parasitaria.  —  Gassmann  and  Schenkel  ^  rei)ort  the  fol- 
lowing case :  — 

Case  I.  G.  B.,  thirty-six  years  old.  Entered  the  hospital  Novem- 
ber 22,  1897.  Disease  of  thirteen  years'  duration.  Had  been  treated 
medically  but  with  no,  or  only  transient,  result. 

X-ray  treatment  was  begun  on  April  12,  1898,  and  was  given  daily 
for  twenty  minutes,  with  the  tube  at  a  distance  of  20  centimetres.  After 
the  ninth  sitting  the  treatment  was  stopped  on  account  of  dermatitis. 

The  folliculitis  disappeared,  and  a  hairless  and  comparatively  nor- 
mal skin  remained. 

December  6.  The  patient  wrote  that  the  parts  treated  had  not 
changed,  but  had  remained  smooth  and  healed. 

Hypertrichosis 

Healthy  but  Superfluous  Hair.  — Jutassy^  has  treated  forty-four  cases 
of  hypertrichosis  with  the  X-rays.  In  these  cases  he  endeavored  to 
produce  a  reaction  that  would  lead  directly  to  depilation,  and  he  also 
tried  the  method  which  Schiff  and  Freund  pursue,  that  is,  by  the  accu- 
mulation of  many  slight  inflammations  to  produce  a  chronic  inflamma- 
tion, and  thus  a  chronic  degeneration  of  the  papillae.  He  states  that 
the  production  of  a  lasting  alopecia  was  brought  about  without  any 
noteworthy  reaction.  His  observations  taught  him  the  need  of  proceed- 
ing cautiously. 

Jutassy  states  that  the  reaction  appears  in  young  people  more  quickly 
and  more  completely  than  with  middle-aged  persons.  With  old  peo- 
ple he  had  had  no  experience.  The  skin  of  blondes  reacts  more  quickly 
and  more  vehemently  than  that  of  brunettes;  strong,  well-developed 
hair  comes  out  in  proportion  easier  than  the  lanugo  hair.  The  reaction 
is  greatest  where  the  centre  of  the  light  falls  ;  therefore,  the  vertical  rays 
are  the  most  efificient.  The  intensity  of  the  reaction  corresponds  to  the 
intensity  of  the  light  used,  the  distance  of  the  tube,  and  the  length  of 
exposure. 

^"Ein  Beitrag  zur  Behandlung  der  Hautkrankheiten  mittelst  Roentgenstrahlen,"  Fort- 
schritte  a.  d.  Geh.  d.  Roentgenstr.,  B.  II. 

^  forischritte  a.  d.  Geb.  d.  Roentgenslr.,  B.  II,  pp.  194-195;    B.  Ill,  H.  3,  p.  1 19. 


THERAPEUTIC    USES   OF   THE   X-RAYS  417 

I  give  one  case  reported  by  Jutassy  :  — 

Case  I.  Hypertrichosis  totalis  faciei  et  colli.  Woman  twenty-five 
years  old.  The  cheek,  chin,  and  neck  were  covered  with  close,  coarse, 
black  hair,  but  there  was  not  much  on  the  upper  lip.  The  face  was 
treated  by  the  rays  from  the  3d  to  the  14th  of  November,  1898;  ten 
sittings  being  given,  three  and  a  half  hours  in  all.  December  2 
with  the  complete  removal  of  the  hair,  a  brownish  red  erythema  set 
in.  The  patient  went  away  with  the  understanding  that  as  soon  as  the 
erythema  disappeared  she  would  return  for  further  treatment.  The 
erythema  disappeared  in  the  beginning  of  the  new  year,  1899,  but  the 
patient  did  not  come  back  until  February,  and  then  there  was  a  slight 
recurrence,  but  only  about  the  corners  of  the  mouth,  and  that  to  a  much 
less  degree.  X-ray  treatment  was  repeated  on  February  5,  6,  7,  — one 
and  a  half  hours  in  all,  —  after  which  an  erythema  showed  itself  and 
;  this  time  more  quickly.  After  the  removal  of  the  hair  a  recurrence 
took  place,  but  only  in  the  neighborhood  of  the  left  corner  of  the  mouth, 
and  the  hair  was  slight  in  quantity,  so  that  another  repetition  of  the 
treatment  seemed  superfluous,  the  more  so  as  these  few  hairs  could  be 
removed  easily  in  half  an  hour  by  electrolysis. 

Freund  states  that  treatment  should  be  stopped  when  the  skin 
appears  of  a  light  red  or  brown  color,  and  the  hair  seems  loose. 
According  to  his  experience  this  occurs  in  hypertrichosis  after  17-25 
sittings;  in  sycosis  and  favus  in  7-13  sittings.  Hypertrichosis  needs, 
he  thinks,  a  second  course  of  treatment,  consisting  of  3-5  short 
daily  sittings,  which  should  be  given  after  an  interval  of  eight  weeks. 
If  this  second  course  of  treatment  is  omitted,  the  hair  usually  returns 
in  about  two  and  one  half  months,  as  generally  the  first  treatment  does 
not  suffice. 

Lymphomata  Colli 

Gocht  ^  reports  the  following  case  :  — - 

Case  I.  A  man  forty-six  years  old  had  been  operated  on  repeatedly, 
and  the  last  time  the  wound  had  not  healed  well,  as  the  beard  kept  up 
a  continual  irritation.  To  get  rid  of  this  hair  he  was  given  daily  treat- 
ment with  the  X-rays.  The  sittings  began  on  April  23,  and  on  June  8 
the  hair  on  the  chin  and  neck  had  all  disappeared,  and  the  wound  had 
closed  smoothly  and  well.  After  two  months  and  a  half  no  hair  had 
grown  out,  though  the  skin  was  more  delicate  than  before.  It  was 
otherwise  normal.     The  removal  of  the  hair  gave  the  desired  relief. 

1  Forischritte  a.  d.  Geb.  d.  Roentgensir.,  B.  I,  p.  17. 
2  E 


41 8     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Psoriasis 

Albers-Schonberg  states  that  in  this  disease  it  has  been  observed  that 
the  scales  can  be  easily  pulled  off  without  bleeding,  after  four  sittings, 
and  adds  that  if  this  is  the  case  an  interval  between  the  sittings  is  indi- 
cated, for  the  skin  that  is  affected  with  psoriasis  is  inclined  to  excori- 
ation when  subjected  to  the  X-rays. 

Acne 

Acne  vulgaris.^  —  Jutassy  observes  that  he  and  others  have  remarked 
the  cure  of  acne  vulgaris  in  cases  where  the  skin  was  treated  by  the 
X-rays  for  some  other  reason  than  the  acne. 

Acne  rosaceae.^  —  Jutassy  also  reports  that  he  is  experimenting  in  his 
laboratory  with  acne  rosaceae,  and  states  that  Schiff  and  Freund  think 
that  the  use  of  the  X-rays  is  indicated  in  obstinate  acne  and  comedones. 

Tuberculosis 

Pulmonary  Tuberculosis.  —  Hahn^  reports  that  a  patient  suffering 
from  chronic  pulmonary  tuberculosis  was  exposed  by  Rieder  to  the 
X-rays,  but  with  no  encouraging  results. 

Dollinger  ^  states  that  Bergonie  and  Mongour  report  two  cases  of 
acute  phthisis  in  individuals  who  were  in  bad  condition  owing  to  poor 
nourishment  and  the  excessive  use  of  alcohol.  The  result  was  nega- 
tive. In  a  case  of  lingering  pulmonary  tuberculosis  the  treatment 
produced  very  slight  results ;  in  a  second  case  there  was  a  rapid  im- 
provement in  the  general  condition  and  the  strength  and  appetite 
increased,  but  the  local  process  remained  unchanged ;  a  third  case 
improved  generally  and  locally  during  the  first  month  of  treatment,  and 
then  severe  digestive  disturbances  appeared. 

Dr.  Sinapius,  in  August,  1897,  published  a  pamphlet  in  which  he 
gives  an  account  of  his  use  of  the  X-rays  in  the  treatment  of  pulmonary 
tuberculosis.  He  cites  a  number  of  cases  in  which  he  states  that  ex- 
cellent results  have  been  obtained,  but  the  diagnosis  was  not  estab- 
lished in  these  cases  and  his  statements  are  not  convincing. 

Laryngeal  Tuberculosis.  —  The  successful  treatment  of  lupus  by  the 
X-rays  should  lead  us  to  try  them  in  laryngeal  tuberculosis. 

1  Fortschritte  a.  d.  Geb.  d.  Roenigenslr.,  B,  III,  H.  3,  p.  119 

2  Ibid.,  B.  Ill,  H.  I,  p.  36. 

3  Ibid.,  B.  II,  pp.  72-73. 


THERAPEUTIC    USES   OF   THE    X-RAYS  419 

Tuberculous  Elbow-joint  and  Wrist.  —  Southgate  Leigh  gives  a  case 
of  a  tuberculous  elbow-joint,  which  is  reported  by  Werner,^  that  was 
exposed  to  the  X-rays  for  two  hours  from  two  to  three  times  a  week. 
After  twelve  hours'  exposure  the  inflammation  had  disappeared,  and 
the  patient  had  been  free  from  recurrence  for  eighteen  months  when 
reported  upon. 

Dollinger^  states  that  Kirmisson  reports  a  case  of  a  tuberculous 
wrist  which  was  much  improved  by  daily  sittings  of  ten  minutes'  dura- 
tion, for  two  and  a  half  months,  and  was  cured  completely  by  elastic 
compression  following  the  X-ray  treatment. 

A  Case  of  Tuberculosis  in  a  Wound  caused  by  a  Burn. 3—  Dr.  Ivar 
Bagge,  of  Goteborg,  Sweden,  reports  a  case  of  a  man,  J.  B.,  forty- 
seven  years  of  age,  who  had  always  been  healthy  and  had  no  tuber- 
culous history.  W^hen  J.  B.  was  thirty  years  old  he  burned  the  left 
back  and  front  of  his  chest  with  boiling  water.  He  went  to  no  phy- 
sician, but  tried  to  heal  the  wound  himself,  and  meanwhile  he  worked 
often  in  a  family  in  which  two  of  the  members  were  suffering  from  tuber- 
culosis. The  wound  healed  for  the  most  part  with  scars,  but  the  unhealed 
parts  were  covered  with  granulations  and  crusts  ;  these  never  healed  com- 
pletely during  the  seventeen  years  ;  they  dried  up  and  then  opened  again, 
suppurated  and  increased.  Finally  the  wounds  became  so  bad  that  the 
patient  could  not  work,  and  therefore  in  August,  1899,  he  went  to  the 
hospital  for  treatment,  and  remained  there  almost  five  months.  During 
this  time  he  took  a  cold  in  his  head,  and  he  had  a  habit  of  putting  his 
fingers  into  his  nose,  and  likewise  of  picking  off  the  crusts  from  the 
wounds  on  his  chest.  Shortly  after  he  recovered  from  the  cold  a  wound 
appeared  in  the  mucous  membrane  of  the  right  nostril.  The  nostril 
swelled  up,  and  an  elevation  the  size  of  a  bean  could  be  seen  on  the 
right  side  of  the  nose.  This  elevation  soon  ulcerated  and  the  new 
wound  increased  in  size.  The  upper  lip  became  affected  and  the  trouble 
spread  to  the  right  cheek.  As  these  wounds  resisted  the  energetic  treat- 
ment applied  in  the  hospital,  the  patient  was  sent,  in  January,  1900,  to 
Dr.  Bagge,  who  applied  the  X-rays  with  the  result  that  the  wounds  on 
the  front  and  on  the  back  were  healed  in  the  course  of  three  weeks, 
and  the  bandage  could  be  taken  off. 

Dr.  Bagge  states  that  the  striking  point  in  this  case  is  the  fact  that 

^  Forischritte  a.  d.  Geb.  d  Roentgensti- .,  B.  Ill,  H.  3,  pp.  122-123. 

2  Ibid.,  B.  II,  p.  72. 

=*  Ibid.,  B.  Ill,  H.  6,  p.  218. 


420     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

the  X-ray  treatment  that  was  applied  only  to  the  front  of  the  chest  like- 
wise healed  the  larger  ulcerations  that  were  on  the  back,  as  well  as 
those  under  the  axilla,  as  quickly  as  those  below  the  clavicle.  This  is 
only  one  case,  and  the  good  results  may  have  been  due  to  some  other 
cause  than  the  X-ray  treatment.  Dr.  Bagge  mentions,  in  connection 
with  this  case,  two  cases  that  he  treated  of  lupus  of  the  hard  palate, 
with  ulcerations.  The  mucous  membrane  of  this  palate  was  healed, 
although  the  rays  had  passed  both  through  the  soft  and  hard  parts  of 
the  face. 

Trigeminal  Neuralgia 

Gocht  ^  reports  the  case  of  a  man  seventy-six  years  old,  who  had  suf- 
fered from  trigeminal  neuralgia  of  the  right  side  for  from  ten  to  eleven 
years,  and  the  pain  came  on  daily  with  such  severity  that  large  doses  of 
morphine  had  been  used  for  years.  The  patient  went  to  Dr.  Gocht  for 
surgical  treatment,  but  instead  was  treated  daily  for  half  an  hour  with 
the  X-rays,  as  an  experiment.  From  the  second  day  on  the  patient  had 
no  more  pain  and  required  no  more  morphine.  On  the  sixth  day  he 
had  a  very  slight  attack.  He  was  then  obliged  to  go  away,  but  a  week 
later  returned.  The  attacks  had  not  returned,  but  the  right  cheek  had 
reddened,  and  the  hair  upon  it,  as  well  as  upon  the  upper  lip  and  chin, 
had  almost  entirely  come  out.  Somewhat  later  the  pain  returned,  but 
to  what  extent  is  not  known. 

New  Growths 

For  some  time  past  attempts  have  been  made  to  treat  various  forms 
of  new  growths  by  means  of  the  X-rays,  and  recently  it  has  become  a 
recognized  method  of  treatment  for  external  forms  in  the  hands  of 
those  who  have  learned  something  of  its  use  in  this  field ;  among 
external  forms  I  include  those  of  the  breast,  and  of  any  part  which  is 
easily  accessible  from  the  exterior,  such  as  portions  of  the  tongue,  the 
larynx,  and  the  cervix  uteri,  if  the  disease  is  in  a  very  early  stage. 

When  more  is  known  about  the  physics  of  the  radiation  from  the 
vacuum  tube,  we  may  be  able  to  separate  the  beneficent  from  the  harm- 
ful radiation  and  thus  be  enabled  to  bring  the  deep-seated  cancers 
within  reach  of  this  method  without  risk  of  burning  the  patient.  It 
now  seems  as  if  the  radiation  from  a  vacuum  tube  had  separate  and 

^  "Therapeutische  Vervvendung  der  Roentgenstrahlen,"  Fortsch>ittt  a.  d.  Geb.  d.  Roent^enstr., 
B.  I. 


THERAPEUTIC    USES   OF   THE    X-RAVS  42 1 

distinct  actions.  First,  prompt  relief  from  pain  takes  place,  second,  the 
process  of  repair  begins  to  be  evident,  and  third,  if  the  treatment  has 
been  pushed  vigorously,  dermatitis  may  follow. 

I  will  refer  briefly  to  some  of  the  early  attempts  to  treat  carcinoma 
by  means  of  the  X-rays,  and  then  take  up  at  more  length  the  subject  of 
the  treatment  of  external  new  growths. 

Carcinoma  of  the  Breast.  —  Gocht^  reports  the  two  following  cases  of 
cancer  of  the  breast ;  first  that  of  a  woman  fifty-four  years  old.  She 
was  treated  daily  for  six  days,  and  felt  better  subjectively,  and  the  pain 
almost  entirely  disappeared.  On  the  seventh  day  she  had  a  sudden  rise 
in  temperature,  and  erysipelas  developed,  which  spread  over  the  back 
and  breast  and  the  whole  right  arm.  A  few  days  afterward  there  was 
profuse  bleeding  from  the  ulcerating  carcinoma,  which  was  followed 
not  long  after  by  death. 

Second  a  patient  forty-six  years  old,  where  the  cancer  had  been 
operated  on  several  times,  the  last  time  being  in  1896.  Treatment  with 
the  X-rays  was  begun  in  November,  1896.  The  pain  subsided  quickly, 
but  when  the  sittings  were  stopped  because  the  apparatus  was  out  of 
order  for  about  twelve  days,  returned,  so  that  morphine  was  again 
necessary.  As  soon,  however,  as  the  sittings  were  renewed,  the  mor- 
phine was  again  omitted.  In  January  and  F'ebruary,  1897,  the  cancer 
increased,  and  in  the  middle  of  the  latter  month  the  patient  was  no 
longer  able  to  be  carried  to  the  X-ray  room.  The  pain  returned  and 
morphine  was  again  used.     The  patient  died  February  26,  1897. 

Carcinoma  of  tJie  StomacJi.  —  Despeignes^  has  treated  a  patient  with 
a  carcinoma  of  the  stomach  by  the  X-rays.  The  sittings  were  given 
twice  a  day  for  half  an  hour,  with  the  result  that  a  week  later  the  pain 
had  diminished,  the  tumor  had  considerably  decreased  in  size,  the  yellow 
color  of  the  skin  had  almost  disappeared,  and  emaciation  made  no  fur- 
ther progress. 

External  Forms  of  Cancer. — Johnson  and  Merrill,  in  an  excellent 
paper  in  the  Philadelphia  Medical  Journal  for  December  8  and  15, 
1900,  give  the  results  of  their  use  of  the  X-rays  in  carcinoma  and 
describe  carefully  six  cases.  They  arrive  at  the  conclusion  that  to  pro- 
duce a  curative  effect  a  so-called  X-ray  burn  must  be  set  up  ;  and  they 
state  that  the  static  machine  and  smaller  coils  are  not  applicable  for  the 
use  of  the  X  rays  in  this  disease. 

^  Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  B.  I.,  p.  16. 
^  Lm.  Semaine  Medicate,  No.  37,  1896,  p.  cxlvi. 


42  2     THE    ROENTGEN    RAYS    IN    MEDICINE    AND   SURGERY 

Thev  select  a  tube  of  low  resistance,  "but  before  using  it  on  a  patient 
its  burning  time  is  determined.  This  is  very  important,  for  we  have 
found  that,  of  two  equally  soft  tubes  operated  on  the  same  current,  one 
may  produce  a  burn  in  three  minutes,  while  with  the  other  an  exposure 
of  thirty  minutes  may  be  necessary  to  effect  the  same  result.  .  .  ." 

"  It  is  our  object  to  produce  a  mild  inflammation  and  pigmentation 
in  and  about  the  diseased  tissue,  gradually  increasing  its  severity,  until 
we  have  a  burn  of  such  depth  that  it  will   require  six  weeks  to  heal  on 


Fig.  223.    H.  N. 


Epidermoid  cancer  of  tlie  lip  before  treatment  witli  the  X-rays.     Front  view. 


the  normal  skin.  The  treatment  is  then  suspended  for  a  month,  and 
if  a  complete  cure  is  not  in  prospect  at  the  end  of  this  time,  the  process 
is  continued  over  those  parts  which  still  resist." 

It  is  well  known  that  cancer,  especially  of  the  face,  may  yield,  not 
only  to  surgical  interference,  but  also  to  the  effect  of  caustics,  which 
are  not  infrequently  used  to  treat  it ;  and  if  relief  is  given  only  by  the 
burning  action  of  a  vacuum  tube,  there  are  other  methods  of  cauteriz- 
ing a  diseased  part  which  are  much  simpler.     Until  this  caustic  action 


THERAPEUTIC    USES   OF   THE   X-RAYS  423 

is  excluded,  it  is  not  demonstrated  that  we  have  a  therapeutic  agent  that 
is  novel  in  its  action  for  the  treatment  of  face  cancer. 

My  own  experience  ^  in  using  the  X-rays  for  the  treatment  of  cancer 
differs  from  the  above  and  has  demonstrated  to  me  that  in  certain  forms 
of  cancer,  the  pain,  odor,  discharge,  and  growth  disappear,  and  that  this 
can  be  brought  about  without  pain  or  inconvenience,  or  a  burn. 

Many  of  my  cases  have  been  treated  with  a  vacuum  tube  that  was 


^ 


Fig.  224.     H.  N.     Epidermoid  cancer  of  the  lip  before  treatment  with  the  X-rays.     Side  view. 

excited  by  a  static  machine.     As  examples  of  the  good  effect  of    this 
treatment,  I  will  cite  the  following  cases  :  — 

Case  I.  H.  N.,  a  young  man  twenty-five  years  old,  who  had  been 
a  patient  of  Dr.  H.  L.  Burrell,  and  by  him  was  kindly  transferred  to 
my  service,  gave  the  following  history :  He  had  always  been  well  and 
strong.  Three  months  ago  he  noticed  a  small  crusted  sore  on  the  right 
side  of  the  lower  lip,  which  he  thought  was  a  coldsore.      It,  however, 

1  "  Xote  on  the  Treatment  of  Epidermoid  Cancer  by  the  Roentgen  Rays,"  Boston  Medical 
and  Surgical  Journal,  ]a.n\id.xw  17  and  April  4,  1901. 


424    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

kept  up  a  constant  scabbing,  and  slowly  grew  larger.  There  was  no 
attendant  pain,  but  it  had  grown  "  fairly  rapidly  "  during  the  past  two 
weeks.     The  patient  came  to  the  hospital  for  operation. 

A  small  bit  of  the  growth  was  removed  and  submitted  to  Professor 
Mallory,  assistant  pathologist  at  the  Boston  City  Hospital,  for  exami- 
nation.    He  reported  that  the  growth  was  an  epidermoid  cancer.     The 


Fig.  225.    H.  N.    After  treatment  with  the  X-rays,     lias  been  well  more  than  two  yeais.    Front  view. 

lesion  on  the  right  half  of  the  lower  lip  was  1.5  centimetres  long  and 
about  I  centimetre  wide ;  it  was  crusted  and  indurated.  A  small  gland 
was  felt  under  the  inferior  maxilla,  just  to  the  right  of  the  symphysis. 
Recently  the  patient  had  complained  of  some  pain  in  the  lower  lip  near 
and  around  the  lesion. 

The   iirst   exposure   to    the    X-rays   was    of    seven    minutes'    dura- 


THERAPEUTIC   USES   OF   THE   X-RAYS 


425 


tion,  and  the  patient  was  placed  about  12  centimetres  from  the 
target  of  the  tube.  The  resistance  of  the  tube  was  equivalent  to 
1.5  centimetres  of  air.  During  the  ensuing  week  daily  exposures 
of    five   minutes'    duration   each   were    made.     All    the    parts   except 


i  Fig.  226.     H.  N.     Alter  treatment  with  the  X-rays.     Has  been  well  more  than  two  years.     Side  view. 

I 

!  those  immediately  around  the  growth  were  carefully  protected  by 
i  means  of  a  shield  made  of  tinfoil  laid  over  blotting-paper,  as 
:  described  in  the  treatment  of  lupus.  At  the  end  of  this  time  the 
I  crust  came  off,  leaving  a  clean  base,  and  the  induration  had  apparently 
'  diminished.     From  this  time  the  treatment  was  about  two  minutes  daily. 


426     THK    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

On  the  eleventh  day  from  the  beginning  of  the  treatment  the  cancer 
was  smaller,  the  induration  was  much  less,  and  cicatricial  tissue  was 
forming,  especially  on  the  right  side  of  the  growth.  The  opening  in 
the  protective  shield  was  then  found  to  be  much  too  large,  and  a  shield 
with  a  smaller  hole  was  made  and  substituted  for  it.  On  the  thirteenth 
day  the  induration  had  disappeared.  On  the  eighteenth  day  the  lip 
showed  marked  improvement,  though  it  had  not  been  as  rapid  during 
the  past  few  days  as  during  the  first  week,  therefore  the   length  of  the 


Fig.  227.    J.  C.    Ep 


ii'l  cancer  before  treatment. 


exposures  was  increased  during  the  next  ten  days  to  fiv^e  minutes  daily. 
From  that  time  the  healing  made  such  good  progress  that  the  time  of 
treatment  was  reduced  to  one  minute,  and  the  distance  of  the  tube 
from  the  patient  was  increased  to  about  20  centimetres.  The  part  was 
kept  clean  by  means  of  a  solution  of  peroxide  of  hydrogen,  which  the 
patient  applied  several  times  a  day.  The  treatment  by  the  X-rays  con- 
tinued in  all  for  about  five  weeks,  but  the  latter  part  of  the  time  it  was 
almost   nominal.     I  wished  to  keep  the  patient  under  observation  until 


THERAPEUTIC    USES   OF   THE   X-RAYS 


427 


complete  healing  had  taken  place  and  be  ready  to  resume  it  should  im- 
provement cease.  There  has  been  no  recurrence  for  more  than  two  years. 
Presumably  with  this  patient  healing  would  have  taken  place  more 
rapidly  had  the  treatment  been  a  little  more  energetic.  Four  photo- 
graphs (see  Figs.  223  to  226),  two  of  which  show  the  appearances 
before  the  treatment  was  begun,  and  two  vievv^s  taken  after  healing  had 
occurred,  speak  for  themselves.  The  enlarged  gland  could  not  be  felt 
after  treatment. 


Fig.  228.     J.  C.     Epidermoid  cancer  during  treatment. 


New  growths  attacking  the  lid  of  the  eye  cannot  well  be  treated 
surgically  without  removing  a  considerable  part,  or  perhaps  the  whole, 
of  the  lid.  This  would  require  a  plastic  operation  also.  By  means  of 
the  X-rays  I  have  found  it  practicable  to  treat  the  disease,  even  when 
extending  to  the  edge  of  the  lid,  without  any  irritation  extending  to  the 
eye  in  consequence  of  this  treatment ;  and  the  treatment  can  be  carried 
on  without  interfering  in  any  way  with  the  usefulness  of  the  patient's 
sight,  or  with  his  work. 


428     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Case  II.  J.  C,  sixty-nine  years  of  age;  carpenter.  Sent  to  me  by 
Dr.  Wadsworth.  Twenty  years  ago  a  small  pimple  started  on  the  outer 
canthus  of  the  right  eye,  but  practically  did  not  increase  in  size  for  a 
great  many  years.      Four  or  five  years  ago  it  was  burnt  with  acid.     Dur- 


FlG.  229.     B.  F.     Epithelioma,     bide  view  before  treatment. 


ing  the  past  six  months  it  began  to  grow  rapidly,  and  ulcerated  in  the 
centre.     There  was  no  pain  but  some  itching. 

Physical  Examination.  —  An  area  on  lower  lid  of  right  eye  2  cen- 
timetres long  by  .5  wide.  There  was  some  ulceration  in  the  centre, 
and  a  well-defined  lower  edge  raised  above  the  surface  of  the  skin, 
which  was  indurated.     (See  page  426.) 


THERAPEUTIC   USES   OF   THE   X-RAYS 


429 


Dr.  Mallory  examined  a  specimen  of  the  growth,  and  found  it  to  be 
an  epidermoid  cancer. 

I  exposed  this  patient  to  the  X-rays,  the  face  being  suitably  pro- 
tected and  the  eyelids  closed,  about  five  minutes  every  other  day  for 
about  four  weeks.  The  slow  improvement  that  took  place  was  soon 
noticeable  by  a  slight  reddening  and  softening  of  the  edges  of  the  indu- 
ration. The  treatment  was  then  omitted  for  two  weeks,  owing  to  necessary 
absence  on  my  part.  On  my  return  I  found  the  improvement,  which 
had  gone  on  during  this  time,  very  striking.     The  raised  indurated  ridge 


Fig.  230.     B.  F.     Front  view  before  treatment. 

had  disappeared,  though  the  induration  lying  under  the  part  which  was 
ulcerated  still  remained ;  the  ulcerated  area  was  not  then  more  than  a 
third  its  original  size,  and  the  skin  about  the  growth  was  slightly  puck- 
ered, having  drawn  together  as  the  growth  diminished.  The  especially 
interesting  feature  in  this  case  is  that  it  continued  to  improve  during 
cessation  of  treatment.  I  have  observed  this  same  characteristic  in 
other  cases. 

Case  III.     B.  F.,  a  man  fifty  years  of  age.     Patient  referred  to  me 
by  Dr.  Burrell.     The  microscopic  examination,  made  in  the  pathological 


430     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

laboratory  of  the  Boston  City  Hospital  by  Dr.  Mallory,  showed  that  the 
patient  had  an  epithelioma  of  the  lip.  The  growth,  which  was  of  four 
years'  duration,  included  nearly  the  whole  of  the  lower  lip,  which  was 
between  two  and  three  times  as  thick  as  normal.  The  whole  lip  was  indu- 
rated, and  had  an  ulcerated  surface  that  was  at  times  covered  by  a  dark 
crust.     The  odor  was  foul,  penetrating,  and  unbearable. 

Treatment.  —  Exposures  of  about  five  minutes  were  made  daily,  ex- 
cept Sundays,  with  the  lip  at  a  distance  of  from  12  to  15  centimetres 
from  the  target  of  the  tube.     The  tube  had  a  resistance  of  about  i  centi- 


FlG.  231.     B.  Y.     After  abiait  six  weeks  treatment. 

metre.  After  six  exposures  the  odor  had  ceased,  and  here  was  less 
induration.  The  hair  on  the  lower  lip,  which  was  exposed  during  treat- 
ment to  the  X-rays,  was  at  no  time  loosened.  Unsuccessful  attempts 
were  made  from  time  to  time  to  pull  it  out  with  the  forceps. 

The  first  two  cuts  (see  Figs.  229  and  230)  were  taken  before  treat- 
ment. The  third  photograph  (see  Fig.  231)  is  a  front  view  taken  about 
six  weeks  after  the  beginning  of  the  treatment.  The  lip  was  then  soft 
and  pliable  throughout,  except  for  a  small  crust;  in  the  centre  of  the  lip 
there  was  a  furrow.  The  fourth  view  (see  Fig.  232)  was  taken  some 
weeks  later  than  Fig.  231.     Healing  was  perfect  and  the  scar  slight. 


THERAPEUTIC    USES   OF   THE   X-RAYS 


431 


It  is  difficult  to  estimate  the  necessary  duration  of  treatment  in  this 
case,  as  it  was  interrupted. 

Case  IV.  Among  the  cases  I  have  found  instructive  is  the  follow- 
ing:— 

U.  K.,  a  man  seventy-three  years  old.  Referred  to  me  by  Dr.  M.  F. 
Gavin.      Diagnosis  :  a  typical  epithelioma  of  the  hand. 


Fig.  232.     B.  f.     About  a  month  later  thait  preceding  figure. 


History.  —  Five  months  previous  to  my  seeing  this  patient,  as  he 
drew  his  hand  out  of  his  pocket  he  tore  off  a  small  wart.  An  ulcer  then 
formed,  which  grew  rapidly.  At  the  time  of  his  entrance  to  the  hospi- 
tal, the  ulcerated  surface  was  7.5  centimetres  long  and  4  centimetres 
wide  and  was  surrounded  by  an  edge  raised  in  parts  i  centimetre  above 
the  surface  of  the  skin,  and  this  edge  was  firmly  indurated  ;  the  whole 
mass  presented  a  cauliflower-like  appearance.  (See  Figs.  233  and  234.) 
Dr.  Mallory  reported  as  follows :  — 


432     THE    ROENTGEN    RAVS   IN    MEDICINE   AND   SURGERY 

"  The  growth  shows  a  typical,  rapidly  growing  epidermoid  carcinoma 
containing  many  epithehal  pearls.     Mitotic  figures  are  numerous.     The 


tit;.  233.     D.  K.     Epidermoid  cancer  of  hand.     Near  the  beginning  of  treatment. 


THERAPEUTIC    USES    OF   THE   X-RAYS 


43. 


surface  of  the  growth  is  ulcerated  ;  the  underlying  tissue  is  infiltrated 
with  many  polynuclear  leucocytes.  The  carcinoma  extends  out  at  the 
edge  for  some  distance  in  the  corium  underneath  the  normal  epidermis." 
(See  Fig.  235,  page  434.) 

Treatment.  —  Daily  exposures  were  made  —  usually  of  five  or  ten 
minutes,  sometimes  of  twenty  minutes'  duration  —  with  the  hand  at  a 
distance  of  15  centimetres  from  the  target  of  the  tube.  Improvement 
began  in  about  one  week,  at  which  time  the  two  photographs,  of  which 


Fig.  234.     D.  K.     Epidermoid  cancer  of  hand.     Side  view  of  Fig.  233. 


cuts  are  shown,  were  taken.  This  improvement  continued,  and  after 
eight  weeks  the  ulcer  had  become  smoother  on  its  surface,  and  was  but 
|6  centimetres  long  by  3.5  centimetres  wide,  and  the  induration  was  largely 
igone.  (See  Fig.  236,  page  435.)  At  this  time  I  had  a  thin  specimen 
I  taken,  reaching  down  to  the  full  depth  of  the  growth  and  from  the 
J  centre  of  the  ulcerated  area  to  well  beyond  the  edge  of  the  growth  into 
,the  healthy  skin,  and  this  was  sent  to  the  pathological  laboratory,  where 
lit  was  examined  at  my  request.  I  give  Dr.  Mallory's  report,  and  also 
ithe  comments  made  by  him  and  Dr.  Councilman  :  — 

i  2  F 


434 


THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 


"  The  ulcerated  area  left  after  treatment  with  X-rays  shows  no  evi- 
dence of  carcinoma  except  at  the  edge  near  and  beneath  the  epidermis, 
where  a  few  small  islands  of  epithelial  cells,  some  of  which  are  dividing 
by  mitosis,  are  present.     The  central  portion  of  the  ulcerated  area  is 


Fig.  235.  A  portion  of  a  section  through  the  carcinoma  before  treatment  with  the  X-ray. 
Magnified  approximately  77  diameters.  The  masses  of  squamous  epithelial  cells  and  the  interstitial  > 
tissue  crowded  with  small  round  cells  are  shown. 


entirely  free  of  any  carcinomatous  growth.     The  base  of  the  ulcer  is 
composed  of  rather  dense  fibrous  tissue,  in  which  are  the  remains  of ! 
epithelial  pearls  often  surrounded  by  young  connective  tissue  cells  andi' 
giant   cells.     Toward  the  surface  is  granulation  tissue  infiltrated  with 


THERAPEUTIC    USES   OF   THE   X-RAYS 


435 


numerous  polynuclear  leucocytes.  The  surface  is  covered  with  more 
or  less  hbrin  containing  leucocytes  in  its  meshes.  The  reaction  on  the 
part  of  the  connective  tissue  to  the  necrotic  growth  is  surprisingly 
slight."     (See  Figs.  237  and  238.) 

Dr.  J.  H.  Wright  kindly  had  made  for  me  in  the  Pathological 
Laboratory  of  the  Massachusetts  General  Hospital  the  excellent  micro- 
photographs  from  which  Figs.  235,  237,  and  238  were  made. 

The  fact  that  near  the  edges  of  the  ulcer  there  were  still  a  few  small 
islands  of  epithelial  cells  may  be  accounted  for  in  perhaps  two  ways  : 


Fic..  236.     D.  K.     Epidermoid  cancer  after  some  treatment  by  the  X-rays,  and  as  it  appeared  when 
the  second  specimen  was  taken  for  microscopic  examination.     (See  Figs.  237  and  238.) 


First,  this  portion  of  the  growth,  where  the  edges  were  much  raised,  was 
thicker  than  the  other  portions  ;  and  second,  the  edges  may  have  been 
more  or  less  protected  by  the  lead  shield  which  was  used  to  prevent  the 
rays  from  striking  the  healthy  skin  near  the  cancer.  If  this  latter  sup- 
position is  correct,  it  shows  that  it  is  of  the  first  importance  to  expose  an 
area  of  apparently  health v  tissue  around  the  growth,  as  well  as  to  expose 
the  growth  itself  to  the  X-ravs.  In  fact  this  should  always  be  done.  It 
is  not  improbable  that  some  of  the  early  cases  of  cancer  treated  by  this 
method  will  recur,  because  this  apparently  healthy  tissue  has  not  been 


436     THE    ROENTGEN    RAYS   IN    MEDICINE    AND   SURGERY 

fully  treated.  But  if  this  recurrence  takes  place,  it  should  not  dis- 
courage us  from  using  this  method  of  treatment,  but  only  be  regarded, 
for  the  present  at  least,  as  showing  that  it  has  not  been  efficiently  car- 
ried out. 


Fig.  237.  A  portion  of  the  section  tlirough  the  centre  of  the  carcinomatous  ulcer  after  treat- 
ment with  the  X-rays.  Magnified  approximately  77  diameters.  The  small  groups  of  necrotic  squamous 
epithelial  cells  and  the  granulation  tissue  in  which  they  are  imbedded  are  shown. 

Two    important    points,  which    Dr.    Councilman    and    Dr.    Mallory 
notice,  are  that  the  central  portion  of  the  ulcerated  area  was  entirely 
free    from    carcinomatous    growth,    and    furthermore,   as    Dr.    Mallory  i 
states  in  his  report,  the  reaction  on  the  part  of  the  connective  tissue  to  i 


THERAPEUTIC   USES   OF  THE   X-RAYS 


437 


the  necrotic  growth  was  surprisingly  slight.     It  would  seem  that  the 
X-rays  have  a  selective  action. 


'Um^/if:^ 


J^- 


Fin.  238.  A  portion  of  the  section  through  the  centre  of  the  carcinomatous  ulcer  after  treatment 
with  the  X-rays.  Near  the  centre  of  the  figure  is  a  small  group  of  necrotic  squamous  epithelial  cells  a. 
Around  this  are  seen  new  formed  connective  tissue  cells,  and  above  and  to  the  right  are  two  multi- 
nucleated giant  cells  b  and  c.  The  group  of  necrotic  epithelial  cells  thus  produces  the  same  reaction 
on  the  part  of  the  surrounding  tissue  as  a  foreign  body  does.    Magnified  approximately  500  diameters. 

Rodent  Ulcer 
Stenbeck,^  of  Stockholm,  reports  the  following  case  of  rodent  ulcer :  — 

^  "  Ein  Fall  von  Hautkrebs,  geheilt  durch  Behandlung  mit  Rontgenslrahlen,"  Mittheilungen 
aus  den  Grenzgebieten  der  Medicin  und  Chirurgie,  VI,  1900,  pp.  347-349. 


438     THE    ROEiNTGEN    RAYS   IN    jMEDICINE    AND    SURGERY 

Christina  A.,  seventy-two  years  of  age.  The  patient  had  two  con- 
fluent ulcers  on  the  nose  ;  the  upper,  on  the  bridge,  having  an  average 
width  of  1.5  centimetres,  and  the  lower,  on  the  nostril,  a  somewhat 
greater  width.  The  glands  were  not  swollen.  The  ulcer  had  been 
treated  with  salves  and  hot  iron. 

Stenbeck  gave  the  patient  treatment  with  the  X-rays  ;  at  first  the 
sittings  were  ten  to  twelve  minutes  long,  with  the  tube  at  a  distance  of 
15  to  20  centimetres.  After  four  sittings  there  was  a  reaction,  and 
after  eight  to  ten  sittings  pus  formed,  which,  however,  soon  diminished 
in  amount.  After  about  thirty-five  sittings  the  cleansing  of  the  ulcers 
began  ;  they  became  smoother,  and  a  new,  thin,  but  smooth  skin 
formed  from  the  edges  inward.  After  this  process  had  begun,  and  the 
ulcers  showed  signs  of  healing,  the  sittings  were  increased  to  fifteen 
minutes,  with  the  tube  at  a  distance  of  10  centimetres.  A  slight 
reaction  ensued,  but  the  new  skin  was  not  thrown  off ;  the  reaction  soon 
passed,  and  complete  healing  followed. 

Stenbeck  states  that  the  ulcer  was  not  examined  microscopically,  as 
the  patient  was  unwilling,  but  that  this  diagnosis  was  made  by  several 
physicians,  and  the  course  of  the  disease  and  the  characteristic  appear- 
ances observed,  demonstrated  that  it  was  a  typical  case  of  skin  cancer 
(rodent  ulcer). 

Dr.  Stenbeck  also  states  that  Dr.  Sjogren  reported  a  case  of  rodent 
ulcer  that  was  not  yet  healed,  at  the  same  medical  meeting,  held  Decem- 
ber 19,  1899,  in  which  the  above  case  was  given. 

In  "  A  Preliminary  Communication  on  the  Treatment  of  Rodent 
Ulcer  by  the  X-Rays,"  ^  Dr.  James  H.  Sequeira  reports  twelve  cases 
treated  by  this  means. 

The  first  of  these  twelve  cases  was  sent  to  Dr.  Sequeira  to  be  treated 
by  the  Finsen  method,  but  as  the  patient  could  not  bear  the  pressure  of 
the  apparatus  which  is  used  to  render  the  parts  under  treatment  anaemic, 
Dr.  Sequeira  applied  the  X-rays  instead,  having  already  had  some  ex- 
perience of  the  value  of  these  rays  in  the  treatment  of  lupus.  Of  these 
twelve  cases,  eight  are  still  under  treatment,  and  four  are  under  obser- 
vation, the  ulcers  having  healed. 

"  In  no  instance  has  there  been  a  disappointing  result.  The  treat- 
ment is  painless,  and  nothing  further  is  required  but  to  cover  the  part 
with  a  simple  antiseptic  dressing.  It  is,  of  course,  too  early  to  say 
anything  as  to  the  permanence  of  the  cures  in  these  cases,  but  I   hope 

^  British  Medical  Jotirual,  February  9,  1901,  pp.  332-334. 


THERAPEUTIC   USES   OF   THE   X-RAYS 


439 


to  be  able  to  make  a  further  communication  upon  the  subject  with  par- 
ticular reference  to  the  histological  changes.  The  immediate  result  is 
all  that  can  be  wished  for,  and  I  feel  justified  in  recommending  the  use 
of  the  X-rays,  at  least  in  the  cases  in  which  complete  removal  by  the 
knife  is  impracticable." 

From  among  my  cases  of  rodent  ulcer  I  will  choose  two  as  examples 
of  the  excellent  results  which  this  method  of  treatment  gives. 

Case  I.  J.  H.,  a  man  seventy  years  old.  Referred  to  me  by 
Dr.  M.  F.  Gavin.  The  growth  —  a  small  specimen  from  which  was 
examined  microscopically  by  Dr.  Mallory,  and  found  to  be  a  carcinoma 
of  the  rodent  ulcer  tyj^e  —  began  fifteen  years  ago.     There  was  a  red 


Fig.  239.     J.  H.     Rodent  ulcer  before  treatment  by  the  X-rays. 

and  somewhat  swollen  annular  area,  about  i  centimetre  wide,  sur- 
rounding the  ulcer. 

The  exposures  were  made  at  a  distance  of  12  centimetres  from 
the  target,  and  were  from  three  to  five  minutes'  duration  daily,  except 
Sundays  during  the  first  four  weeks.  Twenty-four  hours  after  the  first 
exposure,  which  lasted  five  minutes,  a  shrinking  and  slight  puckering 
of  the  swollen  ring  around  the  ulcer  was  noticed.  After  three  ex- 
posures, of  three  minutes  each,  the  redness  and  sweUing  of  this  ring 
had  diminished.  After  six  exposures,  there  was  likewise,  by  measure- 
ment, a  slight  diminution  in  the  size  of  the  ulcer. 

The  order  of  healing  seems  to  be  as  follows  :  the  ulcer  heals  up 


440    THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

from  the  bottom,  and  then  afterward  closes  over.  This  closing  in  of 
the  surface,  though  delayed  at  the  beginning,  takes  place  rapidly  after 
it  is  fairly  under  way.  The  total  duration  of  the  treatment  in  this 
patient  was  nearly  six  weeks.  During  the  last  two  weeks  it  was  applied 
for  only  one  minute  a  day,  and  probably  this  was  unnecessary. 

Case  II.  A.  B.,  a  man  fifty-five  years  of  age.  Referred  to  me  by 
Dr.  David  W.  Cheever.  Rodent  ulcer  of  about  thirty  years'  duration. 
Five  operations  had  been  done,  in  one  of  which  one  of  the  eyes  had 
been  removed.  His  experienced  surgeon  finally  decided  that  further 
operation  was  impossible,  and  referred  the  patient  to  me.     The  growth 


Fig.  240.     J.  H.     Rodent  ulcer  after  treatment. 

involved  the  whole  of  the  orbit,  the  eyebrow,  and  the  side  of  the  nose, 
and  extended  below  the  orbit  on  to  the  cheek,  an  area  of  7  x  8  cms. 
It  has  healed  over  under  treatment  by  the  X-rays. 

Some  of  the  growths  I  have  treated  were  typical  epitheliomas ; 
others  were  of  the  rodent  ulcer  type;  still  others  were  ulcers  that  were 
indurated  and  had  persisted  for  months,  or  in  some  cases  for  years ; 
clinically  these  were  epitheliomas,  but  when  a  specimen  was  examined 
under  the  microscope  they  did  not  present  the  appearances  typical  of 
epithelioma,  and  were  reported  by  Dr.  Mallory  either  as  chronic  inflam- 
matory tissue  or  plasmoma.  It  is  noteworthy  that  all  of  these  cases, 
however,  yielded  to  treatment  by  the  X-rays. 


THERAPEUTIC    USES   OF   THE   X-RAYS  44 1 

The  exposure  of  external  growths,  with  the  target  at  a  distance  of 
10-15  centimetres,  to  the  X-rays  for  a  few  minutes  (usually  five  to  ten) 
two  or  three  times  a  week,  for  several  weeks,  is  in  general  what  is 
required,  or  daily  exposures  may  be  made  for  several  days,  and  repeated 
after  an  interval  of  a  few  days.  Where  the  growth  is  more  extensive, 
a  longer  time  than  this  may  be  necessary.  On  the  other  hand,  in  very 
early  cases,  fewer  exposures  may  suffice. 

I  have  been  unable  to  get  statistics  on  a  large  scale  that  will  show 
the  distribution  of  cancer  in  various  parts  of  the  body,  but  as  an 
example  I  have  taken  the  cases  admitted  to  the  Boston  City  Hospital 
for  a  series  of  years  —  I  have  not  included  those  received  at  the  out- 
patient department  —  and  have  placed  them  in  two  groups,  namely, 
external  and  internal  cases,  as  shown  in  the  following  table.  I  have 
classed  as  internal,  cases  which  may  be  accessible,  such  as  some  cases 
of  the  tongue  and  larynx,  for  example.  The  cases  are  likewise  divided 
into  two  groups,  namely,  cancers  and  carcinomas,  as  they  are  thus 
classed  in  the  records  of  the  hospital. 

The  table  is  intended  merely  to  give  some  indication  of  the  propor- 
tion of  cases  which  might  be  amenable  to  treatment  by  the  X-rays  in  a 
very  early  stage  of  the  disease. 

It  is  desirable,  of  course,  to  begin  this  treatment  at  as  early  a  moment 
as  possible,  in  order  to  avoid  the  chance  of  metastases,  and  also  to  shorten 
the  duration  of  treatment.  It  may  be  that  from  the  surgical  standpoint 
many  would  advise  operative  measures  in  early  cases,  but  I  think  we 
have  now  got  far  enough  in  the  use  of  the  X-rays  to  justify  their  employ- 
ment in  the  early  stages  also,  in  order  that  we  may  teach  the  community 
that  these  growths  may  be  healed  by  a  harmless  and  painless  method  ; 
and  when  this  fact  is  realized  we  will  hope  that  few  of  them  will  be 
allowed  to  advance  to  serious  dimensions  through  delay  and  fear  of  the 
knife.  In  deciding  whether  the  X-rays  should  be  used,  or  an  operation 
done,  it  is  to  be  remembered  that  improvement,  under  the  first  method 
of  treatment  if  properly  carried  out,  may  be  looked  for  within  two  or 
three  weeks  ;  therefore,  a  trial  of  the  X-rays  does  not  require  much  delay. 

Of  course  it  will  be  urged  that  to  carry  out  this  method  requires  a 
good  deal  of  time.  It  is  only  fair  to  suggest  that  with  more  experience 
the  duration  of  treatment  will  probably  be  lessened.  I  find  already  that 
I  have  learned  to  carry  it  out  with  fewer  exposures  than  I  gave  at  the 
beginning. 

It  will  also  be  stated  that  these  growths  may  return.     This  criticism 


442 


THE   ROENTGEN   RAYS   IN    MEDICINE   AND   SURGERY 


CANCERS 

Internal 

Abdomen 5 

Antrum 4 

Axilla lo 

Bladder     6 

Ear  (Mastoid)    ...  i 

Gall  Bladder  ....  2 

Groin 2 

Intestine 8 

Jaw 24 

Larynx 5 

Liver 3 

Lung I 

Moutli 2 

Neck 26 

CEsophagus    ....  7 

Omentum i 

Omentum  (Liver)   .      .  i 

Ovary i 

Palate i 

Pelvis I 

Perineum 3 

Pharynx i 

Prostate 3 

Rectum 51 

Shoulder i 

Side I 

Spine I 

Stomach 14 


TABLE 

Thorax i 

Tongue 23 

Tonsil I 

Uterus 34 

Vagma i 


CARCINOMAS 
/nternal 

Abdomen 3 

Axilla 5 

Bladder     4 

Groin 2 

Hip I 

Intestine 5 

Jaw 5 

Larynx 3 

Leg I 

Liver i 

Lung I 

Neck ID 

Omentum i 

Prostate i 

Rectum 5 

Stomach 3 

Throat 5 

Tongue      5 

Tonsil 2 

Uterus 9 


318 


CANCERS 
External 

Anus I 

Arms I 

Breast 189 

Clitoris I 

Ear I 

Face II 

Foot 2 

Hand 2 

Leg I 

Lip 21 

Nose 4 

Penis 7 

Scrotum i 

Testicle 3 

Vulva 2 

CARCINOMAS 
External 

Breast 61 

Face 4 

Hand I 

Lip 2 

Nose I 

Penis I 

317 
318 

Total 635 


can  only  be  answered  after  a  sufficient  time  has  elapsed  to  demonstrate 
whether  or  not  the  cure  is  permanent.  As  already  pointed  out,  we 
should  bear  in  mind  that  some  of  these  relapses,  should  they  occur,  may 
be  the  result  of  inefficient  treatment,  and  may  mean  simply  that  we  have 
not  yet  learned  how  to  employ  it  in  the  best  way. 

This  new  therapeutic  agent  gives  us  a  method  of  treatment  which  is 
painless  and  useful  in  certain,  if  not  all,  forms  of  external  cancer  of 
not  great  depth  ;  how  efficient  it  will  prove  to  be  it  will  take  two  or 
three  years  to  decide  ;  but  if  there  is  a  recurrence,  treatment  could  be 
again  instituted.     The  first  steps  in  this  field  have  been  taken,  and  it 


THERAPEUTIC   USES   OF   THE   X-RAYS  443 

now  remains  to  study  the  method  carefully  with  the  view  of  finding  out 
the  best  modes  of  procedure,  and  of  determining  its  limitations.  This 
is  a  question  of  time  and  careful  observation. 

Where  the  X-rays  are  used  for  purposes  of  examination,  there  is  now 
no  risk  of  any  burn  or  inconvenience  to  the  patient ;  but  where  they  are 
used  for  therapeutic  purposes,  it  is  at  present  necessary  to  have  the  tube 
very  near  him  ;  and  there  is,  therefore,  greater  risk  of  setting  up  an 
X-ray  burn  than  there  is  when  the  rays  are  used  for  purposes  of  diag- 
nosis. But  if  proper  care  is  exercised,  I  do  not  think  that  it  is  neces- 
sary to  cause  a  burn  ;  in  none  of  my  cases  of  external  growths  has  one 
occurred. 

This  subject  is  still  so  new  that  all  opinions  about  it  must  necessarily 
be  tentative.  The  special  points  that  my  experience  thus  far  suggests 
may  be  thus  summarized  :  — 

1.  This  treatment  is  adapted  to  external  new  growths  which  have  not 
great  depth,  though  they  may  cover  much  surface. 

2.  The  treatment  causes  no  pain. 

3.  There  need  be  no  delay  on  account  of  dread  of  the  knife. 

4.  Pain  and  odor  are  relieved. 

5.  Healing  follows  without  causing  a  burn. 

6.  The  results  from  a  cosmetic  standpoint  are  excellent. 

7.  Treatment  can  be  carried  on  without  the  work  in  which  the  patient 
is  engaged  being  given  up. 

8.  Signs  of  improvement  may  be  seen  within  two  or  three  weeks. 

9.  In  the  larger  forms  of  external  growths  an  operation  might  first 
be  done  to  remove  the  growth  so  far  as  possible,  and  then  the  X-rays 
may  be  applied. 

The  disadvantages  are:  — 

1.  The  apparatus  is  expensive  and  difificult  to  use  properly,  and  with 
its  present  capacity  the  X-rays  do  not  exert  their  full  action  through 
a  great  thickness  of  tissue. 

2.  The  treatment  may  have  to  be  continued  for  some  time. 

A  therapeutic  measure  cannot,  of  course,  point  out  the  cause  of  a 
disease  ;  but  it  may  throw  suggestive  light  upon  it.  For  example,  in 
the  radiation  from  a  vacuum  tube,  good  results  are  produced  in  a 
disease  where  the  cause  is  known  to  be  due  to  a  microscopic  organism ; 
for  instance,  tuberculosis  of  the  skin,  or  lupus,  yields  more  or  less  well 
to  the  action  of  this  agent ;  but  syphihtic  growths,  it  is  said,  do  not  yield 
readily  to  this  method  of  treatment.     The  clinical  picture  which  healing 


444     THE    ROENTGEN    RAVS   IN    MEDICINE   AND   SURGERY 

cancers  present  is  quite  suggestive.  Their  response  to  treatment  in 
certain  cases  is  immediate,  sometimes  within  two  or  three  days  ;  and, 
further,  in  some  of  the  cases  improvement  continues  for  a  time  after 
the  exposures  have  been  stopped.  These  facts,  taken  'together  with  the 
microscopic  appearances  after  treatment,  suggest  that  cancer  is  pro- 
duced by  some  living  cause ;  and  also  that  the  radiation  from  a  vacuum 
tube  —  probably  the  X-rays  —  interferes  with  its  life. 

Internal  Forms  of  Cancer 

As  yet  we  have  only  begun  the  use  of  this  new  therapeutic  agent, 
and  there  is  much  to  be  learned,  both  on  the  side  of  the  physics  of  the 
X-rays  and  on  that  of  an  intelligent  application  of  them.  Therefore 
until  I  have  had  still  further  experience  with  these  forms,  I  prefer  not 
to  discuss  this  side  of  the  subject.  I  am  about  to  try  a  75  cm.  (30  inch) 
coil  in  these  cases. 

Rodent  Ulcer  treated  bv  Finsen's  Light  Treatment 

Drs.  Morris  and  Dore,^  in  a  paper  on  "  Finsen's  Light  Treatment  of 
Lupus  and  Rodent  Ulcer,"  point  out  the  conditions  which  are  favorable, 
and  those  which  are  unfavorable,  for  this  treatment.  I  refer  to  it  here, 
as  the  question  may  arise  as  to  whether  this  treatment,  or  that  of  the 
X-rays,  is  to  be  preferred.  It  seems  probable  that  in  most,  if  not  in 
all,  cases,  the  treatment  by  the  X-rays  will  replace  that  of  Finsen. 

"  unfavorable  conditions  for  finsen's  method 

"  A.    Those  which  hinder  the  penetration  of  the  light,  and  so  prevent  a  good  reaction  :  — 

1.  Scarring,  especially  from  scraping,  when  the  cicatricial  tissue  is,  as  a  rule,  very- 

dense. 

2.  Pigment  at  ion.  which  intercepts  the  ultra-violet  rays. 

3.  Great  vascularity,  because  it  is  more  difficult  to  express  the  blood  from  the 

part,  and  unless  the  tissues  be  made  anaemic  the  rays  will  not  penetrate. 

4.  Great  depth  below  the  snrfsce,  with  which  may  be  included:   (.4)  Thickness 

and  induration  of  the  nodules  ;  (5)  surrounding  inflammation  and  induration  ; 
(C)  confluence  of  the  nodules. 

"  B.    Difficulties  of  position :  — 

I.  On  the  skin;  for  example,  when  the  disease  is  situated  near  the  eye  special 
compressors  have  to  be  used,  and  it  is  sometimes  difficult  to  adapt  even  these 
to  the  surface  to  be  treated,  or  on  the  eyelid,  when  it  is  impossible  to  apply 
adequate  pressure. 

1  "  Remarks  on  Finsen's  Light  Treatment  of  Lupus  and  Rodent  Ulcer,"  British  Medical 
Journal,  February  9,  1901,  pp.  326-332. 


THP:RAPEUriC    USES   OF   THE    X-RAVS  445 

2.  On  the  viucous  iiiembrane  ;  the  interior  of  the  nose  and  mouth  is  inaccessible, 
with  the  exception  of  the  gums  and  Hps,  which  can  be  treated,  the  latter  bv 
eversion.  (In  these  cases  the  combination  of  X-rays  with  F'insen's  treat- 
ment has  been  found  most  successful.) 

"  C.    Extent  of  the  disease  :  — 

"  As  only  a  small  area  can  be  treated  each  day,  very  extensive  cases  are  unfa- 
vorable, both  from  the  long  duration  of  the  treatment  and  the  fact  that  while 
one  part  is  being  treated  the  disease  may  be  spreading  in  another. 

"favorable  conditions 

"  Conversely,  cases  are  favorable  where  the  disease  is  limited  to  a  small  area,  is  superficial, 
is  not  spreading,  and  has  not  undergone  previous  treatment,  especially  operative." 

The  X-Rays  as  an  Analgesic 

Werner  ^  reports  on  two  cases  which  Southgate  Leigh  presented 
before  the  Seaboard  Medical  Association.  The  first  was  a  youth  who 
had  been  shot  in  the  thigh.  A  bad  swelling  appeared  at  the  knee,  and 
was  so  painful  that  the  slightest  movement  was  impossible.  The  physi- 
cian who  took  a  radiograph  of  the  thigh  had  so  poor  an  apparatus  that 
the  patient  was  exposed  four  hours  to  the  rays.  On  the  following  day 
he  was  free  from  pain,  and  on  the  third  day  could  walk. 

Another  case  was  that  of  a  patient  suffering  from  gallstones.  The 
X-ravs  were  used  for  diagnostic  purposes.  The  stone  was  not  found, 
but  the  patient  was  free  from  pain  and  had  no  further  gallstone  colic. 

Articular  Rheumatism 

Schmid-Monnard^  gives  a  short  report  of  an  article  by  Sokolow  on 
the  cure  of  articular  rheumatism  in  children  by  the  X-rays.  Soko- 
low treated  four  cases  with  good  results.  The  children  were  covered 
with  a  woollen  cloth  and  exposed  to  the  X-rays  for  ten  to  twenty  minutes. 
The  tube  was  at  a  distance  of  50-60  centimetres.  The  first  case  was  a 
girl  of  nine  years  who  was  suffering  with  pain  and  swelling  in  the  right 
and  left  wrist,  finger,  and  knee.  The  pain  disappeared  after  the  second 
sitting.  The  second  was  a  girl  fourteen  years  old  who  had  violent  pain 
and  swelling  in  the  knees,  which  disappeared  after  the  first  sitting. 
The  third  was  a  girl  of  three  years  of  age  who  had  violent  pain  and 
swelling  in  the  knees,  which  diminished  after  the  third  sitting.     After 

1  Foi-fschritte  a.  d.  Geb.  d.  Roenlgenstr.,  B.  Ill,  H.  3,  pp.  122-123. 
-  //'/(/.,  15.  I,  p.  209. 


446    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

four  days  the  swelling  was  reduced  3  centimetres  in  circumference. 
The  last  case  w^as  a  girl  of  thirteen  years  who  had  suffered  from 
chronic  rheumatism  and  heart  disease  for  five  years.  The  disease  grew 
worse  ;  the  pain  was  violent ;  there  was  swelling,  and  the  knee  was  bent 
at  an  angle  of  45°.  After  each  application  of  the  X-rays  the  leg  could 
be  straightened  more ;  the  pain  diminished,  and  disappeared  after  the 
fourth  sitting. 

Immelmann  ^  reports  on  an  article  by  Stenbeck  (of  Sweden)  regarding 
the  treatment  of  articular  rheumatism  with  the  X-rays.  Fifty-two  pa- 
tients in  all  were  exposed  to  the  rays ;  forty  per  cent  were  much  im- 
proved ;  forty  per  cent  felt  subjectively  better;  and  twenty  per  cent 
gave  an  entirely  negative  result. 

Summary  of  Directions  concerning  Apparatus  and  Length  and  Fre- 
quency of  Sitting.  —  It  is  evident  that  experience  in  using  the  X-ray 
apparatus  is  essential  before  an  attempt  is  made  to  employ  the  X-rays 
for  treatment.  There  are  two  sets  of  precautions,  which  should  be 
taken  when  using  these  rays  as  a  therapeutic  agent :  first,  those 
relating  to  the  apparatus  ;  and  second,  those  relating  to  the  patient. 
The  exact  resistance  of  the  tube  should  be  known,  as  it  is  stated  that 
tubes  of  low  resistance  are  more  efficient  for  treatment  than  those  of 
high  resistance.  The  tube  should  be  enclosed  in  a  box  of  such  a 
character  as  to  protect  the  patient  by  permitting  the  rays  to  issue  only 
in  the  desired  direction,  and  a  grounded  aluminum  screen  should  be 
interposed  between  the  tube  and  the  patient.  The  patient  should  further 
be  protected  by  a  shield  made  of  blotting-paper  and  tinfoil  or,  for  the 
face,  a  mask  of  gauze  or  paper  painted  with  white  lead. 

The  time  of  the  exposure,  the  distance  of  the  tube  from  the  patient, 
and  the  frequency  of  the  exposures  must  be  determined  for  each  indi- 
vidual, each  disease,  and  each  apparatus.  In  general  it  is  well  that 
the  target  should  be  placed  at  a  distance  from  the  patient  of  from  15  to 
20  centimetres,  and  that  the  exposures  should  last  from  five  to  twenty 
minutes,  and  should  be  given  two  or  three  times  a  week.  If  at  any  time 
redness  or  bronzing  of  the  skin  takes  place,  the  exposure  should  be  sus- 
pended until  these  effects  have  disappeared  ;  for  if  the  exposures  are 
continued  under  these  circumstances,  serious  injury  may  result.  The  ill 
effects,  if  any  occur,  may  not  appear  for  a  week  or  more  after  exposure.  : 

No  substances  such  as  oxide  of  zinc,  iodoform,  or  aristol  should  be  ^ 

1  Fortsthriile  a.  d.  Geb.  d.  Koentgenstr.,  B.  II,  p.  227. 


THERAPEUTIC   USES   OF   THE   X-RAYS 


447 


used  in  local  applications  while  this  treatment  is  carried  on,  as  they 
obstruct  the  passage  of  the  X-rays  and  vitiate  their  effect. 

Changes    produced    in    the    Skin    by    Exposure    to    an    Excited 
Vacuum  Tube,  and  their  Causes 

Jutassy  ^  states  that  short  and  weak  exposures  cause  hyper?emia  and 
erythema  ;  long  and  intense  exposures  produce  ulcers  ;  the  effect  does 
not  show  itself  at  once  but  after  a  shorter  or  longer  time.  The  X-ray 
dermatitis  heals  tolerably  quickly  and  leaves  a  fine,  smooth  scar,  except 
when  ulcers  penetrating  deep  down  into  the  cutis  are  produced,  which 
easily  cause  necrosis,  and  heal  with  great  difficulty,  and  in  this  respect 
are  Uke  torpid  specific  ulcers.  This  necrosis  is  differentiated  from  other 
necroses,  according  to  the  investigation  of  Gassmann,  in  that  it  also  dis- 
turbs the  structure  of  the  blood  vessels.  Unna,  who  had  the  opportunity 
of  examining  the  human  skin  suffering  from  dermatitis  erythematosa 
produced  by  exposure  to  an  excited  vacuum  tube  found  such  changes 
that  he  concluded  the  X-rays  attacked  the  most  resistant  tissues  of  the 
skin,  and  by  this  means  he  explained  the  long  continuing  cumulative 
action  observed. 

Jutassy  also  touches  upon  other  histological  changes,  namely,  the 
atrophy  of  the  sweat  and  sebaceous  glands,  as  well  as  the  papillae  of  the 
hair  (Kibby  and  Jutassy)  and  the  obliteration  of  the  capillaries  (Gass- 
mann and  Jutassy),  and  adds  that  Destot  explains  the  pathological 
changes  in  a  tropho-neurotic  way  ;  Kaposi  seeks  a  reason  for  them  in  the 
paresis  of  the  blood  vessels  ;  and  Bordier,  in  the  disturbance  of  the 
nutrition  of  the  tissues,  because  he  found  that  under  the  action  of 
the  X-rays  the  osmosis  in  the  tissues  of  animals  as  well  as  of  plants  was 
delayed. 

Cause  of  the  So-called  X-Ray  Burn 

H.  D.  Hawks  {Electrical  Review,  August  12,  1896)  reported  that 
he  had  severely  burned  himself  with  the  X-rays. 

W.  M.  Stine  (in  the  Electrical  Review  for  November  18,  1896)  stated 
that  the  burns  consequent  on  an  exposure  of  the  body  to  an  excited 
vacuum  tube  were  not  due  to  the  X-rays,  but  to  the  ultra-violet  light 
coming  from  the  tube. 

Elihu  Thomson  {Electrical  Reviezu  for  November  25,  1896)  gave  it 

"^  Fortschritte  a.  d.  Geh.  d.  Roeulgenstr.,  B.  Ill,  H.  3,  pp.  1 1 8-1 1 9. 


448     THE   ROENTGEN   RAYS   IN    MEDICINE   AND   SURGERY 

as  his  opinion  that  the  effects  produced  were  not  electrostatic  in  their 
origin,  as  had  been  suggested,  but  were  due  to  the  chemical  activity  of 
the  Roentgen  rays. 

Tesla  {Electrical  Review,  December  2,  1896)  wrote  that  the  burns 
were  not  due  to  Roentgen  rays,  but  to  ozone  that  was  generated  on  the 
skin,  and  possibly  to  a  small  extent  to  nitrous  acid.  He  therefore 
interposed  a  screen  made  of  aluminum  wire,  that  was  connected  with 
the  ground,  between  the  tube  and  the  person,  and  no  burns  occurred. 
Before  he  took  this  precaution  one  of  his  assistants  had  been  burned. 

'KoWms  {Electrical  Revieiv,  ]^i\\\2ivy  5,  1898)  exposed  his  hand  to  a 
tube  the  resistance  of  which  was  so  high  that  no  current  could  be  forced 
through  it  with  the  generator  used,  and  therefore  no  X-rays  were  pro- 
duced ;  yet  the  hand  was  burned.  This  experiment  showed  that  the 
so-called  X-ray  burns  could  be  produced  by  electricity,  but  did  not  show 
that  they  could  not  also  be  caused  by  the  X-rays. 

Trowbridge  {American  Journal  of  Science,  1898,  page  129)  stated 
that  the  "  so-called  X-ray  burn  is  due  to  an  electrification  —  a  discharge 
at  the  surface  of  the  skin  —  and  this  electrification  may  or  may  not  be 
accompanied  by  X-rays."  Trowbridge  exposed  his  hand  to  the  brush 
discharge  of  a  generator,  with  the  result  that  a  typical  X-ray  burn  was 
produced. 

Elihu  Thomson  {American  X-Ray  Journal,  November,  1898)  stated 
that  burns  were  produced  by  the  X-rays,  and  chiefly  by  those  rays  that 
are  produced  by  a  "  soft  tube  " ;  that  is,  one  of  low  resistance. 

Bacteria 

effect  of  x-ravs  on  bacteria 

Mink.  Typhoid  bacillus.  —  Gocht  ^  reports  that  Mink,  starting  with 
the  fact  that  daylight,  sunlight,  and  electric  arc  light  weakened  and 
injured  bacteria  growing  in  culture  media,  exposed  typhoid  bacilli  on  an 
agar  plate  to  the  X-rays  for  half  an  hour  without  any  injurious  effect; 
he  then  exposed  them  for  thirty-five  minutes  and  without  any  note- 
worthy result ;  but  fewer  colonies  grew  on  the  portion  of  the  plate  ex- 
posed to  the  rays.  Later  reports  from  Mink  show  that  he  exposed 
typhoid  bacilli  to  the  X-rays  for  eight  consecutive  hours  without  any 
injurious  effects  worth  mentioning. 

'^  Fortst/iriUe  a.  d.  Geh.  d.  Roentgenstr.,  B.  I,  1897-1898,  p.  34. 


THERAPEUTIC    USES   OF   THE  X-RAYS 


449 


Von  Wolfender  and  Forbes  Ross  ^  report  experiments  with  the  bacillus 
prodigiosiis.  The  cultures  were  grown  on  potato  and  carried  on  to  the 
fifth  generation.  The  coil  used  had  a  spark4ength  of  i8  inches;  volt- 
age i6;  amperage  8  to  lO.  The  exposure  to  the  rays  was  fifty  or  sixty 
minutes,  and  the  test  tube  was  placed  at  a  distance  of  6  inches  from  the 
vacuum  tube.  The  writers  state  that  a  single  exposure  increased  the 
growth  markedly ;  further  exposure  stimulated  the  growth  so  as  to 
deprive  the  bacilU  of  their  power  to  form  pigment  when  subjected  to 
warmth,  but  this  power  was  recovered  when  subjected  to  cold,  and  a 
larger  amount  of  pigment  was  formed  than  originally,  but  it  was  slightly 
different  in  color;  up  to  the  fifth  generation  the  result  of  an  hour's 
exposure  was  to  produce  an  exuberant  growth.  The  writers  observed 
changes  in  the  protococcus. 

The  natural  comment  upon  one  experiment  is  that  the  glass  of  the 
test  tube,  if  thick,  would  obstruct  the  passage  of  the  X-rays. 

Beck  and  Schultz.  —  Rieder^  reports  that  Beck  and  Schultz  have 
experimented  with  color-p7'odiicing  bacteria.  The  bacteria  were  planted 
in  agar  on  Petri  dishes.  The  induction  coil  used  had  a  spark-length  of 
12  centimetres,  the  tube  was  at  a  distance  of  25  centimetres,  and  the 
bacteria  were  exposed  for  from  twenty  minutes  to  two  and  a  half  hours 
to  the  X-rays.  Twenty-four  hours  after  the  exposure  all  the  bacteria 
used  in  the  experiment  had  grown  well,  however,  and  there  was  no  dif- 
ference to  be  seen  in  the  color  produced  by  these  and  those  that  were 
protected  from  the  rays  by  sheets  of  lead. 

Berton  has  made  experiments  with  bouillon  cultures  of  dipJitJicria 
bacilli  and  exposed  them  to  the  X-rays  sixteen,  thirty-two,  and  sixty-four 
hours  respectively.  After  each  exposure  two  guinea  pigs  were  inocu- 
lated with  the  culture  that  had  been  subjected  to  the  rays,  and  two  other 
guinea  pigs,  as  a  control,  with  the  ordinary  bouillon  culture  of  diphtheria. 
Both  sets  of  guinea  pigs  died  quickly. 

Sabrazes  and  Riviere  experimented  with  the  bacillus  prodigiosus. 
The  tube  was  placed  at  a  distance  of  1 5  centimetres,  and,  in  order  to 
exclude  the  light  rays,  the  dishes  were  covered  with  black  paper.  The 
exposure  lasted  one  hour  a  day  for  twenty  days,  and  produced  no  effect 
on  the  bacilli  as  to  color,  morphological  properties,  or  growth.  These 
investigators  also  experimented  with  the  X-rays  on  leucocytes  and  with 

1 "  A  Preliminary  Note  on  the  Action  of  Roentgen  Rays  upon  the  Growth  and  Activity   of 
Bacteria  and  Microorganisms,"  Lancet,  1898,  p.  1 75 2. 
^  Miinchener  Med.  Wochenschr.,  1898. 

2  G 


450     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

the  heart  of  a  frog,  but  could  see  no  effect  upon  either  although  the 
exposure  lasted  over  one  hour. 

J.  Brunton  Blaikie  obtained  the  same  negative  results  in  his  ex- 
periments with  cultures  of  tubercle  bacilli  and  with  guinea  pigs  inocu- 
lated with  diphtheria  toxine  after  an  eight  hours'  exposure  to  the 
X-rays. 

Rieder.  —  In  the  following  described  experiments  with  various  bac- 
teria, Rieder  used  a  voltohm  induction  coil  with  a  spark-length  of  30 
centimetres  and  three  hundred  interruptions  per  minute.  The  cultures, 
on  an  average,  were  placed  at  the  distance  of  10  centimetres  from  the 
target,  in  order  that  they  might  be  exposed  to  a  direct  and  close  action 
of  the  rays. 

The  cultures  were  placed  in  Petri  dishes  that  were  covered  during 
the  exposures  with  a  piece  of  lead,  out  of  the  centre  of  which  a  hole  had 
been  cut.  The  exposures  lasted  from  forty-five  minutes  to  three  hours. 
In  some  cases  the  hole  in  the  centre  of  the  lead  was  covered  with  black 
paper  that  was  impervious  to  daylight,  in  order  that  the  X-rayed  part 
might  show  unmistakably  the  effect  of  the  Roentgen  rays  on  the 
bacteria.  The  action  of  the  X-rays  proved  to  be  the  same  whether  or 
not  the  hole  was  covered  with  this  paper. 

Cholera  Vibriones.  —  The  cultures  of  cholera  vibriones  were  exposed 
to  the  X-rays  for  forty-five  minutes  and  were  then  put  into  an  oven  that 
was  heated  to  37°  C.  When  the  dishes  were  taken  out  and  their  con- 
tents examined  macroscopically  and  microscopically,  it  was  found  that 
the  centre  of  the  dish  corresponding  to  the  hole  was  free  from  colonies, 
whereas  between  the  circumference  of  the  hole  and  that  of  the  dish 
there  were  very  numerous  colonies.  The  culture  medium  in  this  case 
was  agar. 

Bacterium  Coli. —  With  these  bacteria  gelatine  was  used  as  a  culture 
medium,  and  the  cultures  were  exposed  about  an  hour  and  then  placed 
in  the  oven  after  an  interval  of  thirty-six  hours,  with  the  result  that 
there  were  many  fewer  colonies  in  the  part  of  the  dishes  under  the  hole 
than  the  portion  under  the  lead. 

Staphylococcus  Pyogenes  Aureus.  —  The  same  positive  result  was 
obtained  in  this  case  by  means  of  a  short  exposure,  the  culture  medium 
used  being  gelatine. 

StapJiylococcus  Pyogenes.  —  In  this  experiment  the  time  of  exposure 
was  only  about  forty  minutes,  and  the  result,  although  positive,  was  not  so 
striking  as  in  the  other  cases.     The  culture  medium  used  was  agar. 


THERAPEUTIC    USES   OF   THE   X-RAYS  45 1 

DipJithcria  Bacillus.  —  Blood  serum  cultures  of  diphtheria  bacilli  were 
exposed  for  nearly  an  hour  to  the  X-rays  and  then  placed  in  an  oven 
heated  to  37°  C.  After  remaining  there  for  almost  two  days  only  a  few- 
colonies  were  to  be  seen  in  the  centre  of  the  dish  open  to  the  rays, 
whereas  under  the  lead  they  were  very  numerous. 

Typhoid  Bacillus.  —  These  bacilli  were  grown  on  agar  plates ;  the 
part  of  the  dish  exposed  to  the  X-rays  was  almost  free  from  colonies,  but 
they  grew  very  close  to  the  circular  opening,  forming  a  white  ring. 

These  experiments  showed  that  these  bacteria,  when  grown  in  agar, 
blood  serum,  or  gelatine,  were  killed  by  the  X-rays  when  exposed  to 
them  for  about  an  hour.  In  other  words,  bacteria  outside  of  the  body, 
but  living  in  suitable  media,  can  be  deprived  tolerably  quickly  by  the 
X-rays  of  capacity  for  further  development.  Rieder  adds  that  it  is  not 
necessary  to  kill  the  bacteria  inside  the  human  body,  but  that  to  check 
their  development  will  probably  be  sufficient,  for  the  natural  guardian 
of  the  organism,  namely  the  blood,  with  its  strong  bactericidal  action, 
can  complete  the  destruction  of  the  pathogenic  germs. 

Effects  of  X-Rays  on  Developed  Colonies.  —  Rieder  then  experimented 
with  developed  colonies,  and  found  in  the  case  of  the  cholera  colonies 
that  the  bacteria  were  killed  after  an  exposure  of  two  hours,  but  the 
gelatine  cultures  of  bacterium  coli  which  had  been  in  the  oven  twenty- 
four  hours,  before  the  exposure  of  an  hour  to  the  rays,  showed  colonies 
in  the  exposed  part  of  the  dish  which  on  the  average  were  as  large  in 
size  as  those  on  the  protected  part,  although  fewer  in  number ;  which 
seemed  to  indicate  that,  though  the  rays  could  prevent  the  develop- 
ment of  new  colonies  in  this  case,  they  could  not  stop  those  already 
existing. 

Tubercle  Bacilli  Cultures.  —  Eight  dishes  containing  a  solution  of 
extract  of  beef,  glycerine,  and  pepton  were  sterilized  and  spread  with  a 
thin  layer  of  a  fresh  bouillon  culture  of  tubercle  bacilli ;  four  of  these 
dishes  were  then  exposed  to  the  X-rays  for  over  an  hour,  after  which 
exposure  they  and  the  unexposed  dishes  were  placed  in  an  oven  heated 
to  37°  C.  A  week  later,  in  the  unexposed  dishes  there  was  a  luxuriant 
growth  of  tubercle  bacilli ;  in  three  of  the  exposed  dishes  the  growth 
was  diminished,  and  in  the  fourth  there  was  scarcely  any  growth  to  be 
seen. 

The  striking  point  in  these  experiments  is  the  directly  opposite  results 
reached  by  Rieder  from  those  obtained  by  other  investigators.  Rieder 
ascribes  this  difference  to  the  difference  in  the  apparatus. 


452     THE    ROKNTGEN    RAYS    L\    MEDICINE   AND   SURGERY 

Effect  of  Concentrated  Light  on  Bacteria 

Kiimmell^  reports  two  parallel  series  of  experiments  made  by  Finsen 
with  concentrated  blue  light  and  the  direct  arc  light,  the  source  of  light 
being  75  centimetres  distant,  on  cultures  of  micrococcus  prodigiosus, 
bacterium  coli,  typhoid  bacilli,  etc.  The  concentrated  light  diminished 
the  power  of  growth  in  one  to  one-half  hours,  and  killed  the  bacilli  in 
eight  to  nine  hours,  whereas  the  concentrated  blue  light  diminished 
their  capacity  for  development  in  four  to  five  minutes,  and  killed  the 
bacilli  in  fifteen  to  twenty  minutes. 

Effect  of  X-Ravs  on  Animals  inoculated  with  Bacteria 

Rieder,^  following  his  experiments  with  the  X-rays  on  bacteria  cul- 
tures, made  a  series  of  experiments  regarding  the  action  of  these  rays 
on  various  animals,  namely,  mice,  rabbits,  and  guinea  pigs.  The  animals 
were  inoculated  with  virulent  streptococci,  staphylococci,  etc.,  and  then 
exposed  immediately  to  the  X-rays.  The  results  were  negative.  Rieder 
then  injected  animals  with  tubercle  bacilli  with  results  which  differed 
little  from  those  of  Miihsam  (see  below).  The  tuberculous  disease  of 
the  internal  organs  generally  developed  later  in  the  X-rayed  animals 
than  in  the  control  animals  ;  the  local  tuberculosis  was  delayed  and  in 
many  cases  also  the  general  infection ;  nevertheless  the  animals  died. 

Kratzenstein '^  reports  on  Miihsam's  experiments  with  twenty-six 
guinea  pigs  that  were  inoculated  with  tuberculosis  ;  his  observations  led 
him  to  the  conclusion  that  the  X-rays  are  not  in  a  position  to  arrest 
general  tuberculosis,  but  can  modify  the  local  disease.  With  a  few 
exceptions  the  X-rayed  animals  survived  the  control  guinea  pigs,  and 
at  dissection  showed  that  the  disease  was  not  so  extensive. 

Lortet  and  Genoud. — Took  eight  guinea  pigs  of  equal  weight  and 
size,  and  injected  into  the  right  inguinal  region  a  fluid  mixed  with 
the  powdered  spleen  of  a  very  tuberculous  guinea  pig.  Two  days  later 
three  of  these  guinea  pigs  were  exposed  at  the  point  of  injection  to  the 
X-rays  for  an  hour  a  day  for  two  months,  with  the  result  that  they 
kept  well,  gained  in  weight,  had  no  ulcers,  and  the  inguinal  glands  were 
hard  and  of  normal  size.     The  remaining  five  guinea  pigs  grew  thin, 

'  Centralblatt  filr  Oiinirgie,  April,  1898. 

^  Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  B.  Ill,  H.  T,  1899.  p.  36. 

3  Ibid.,  B.  II,  1898-1899,  p.  47. 


THERAPEUTIC    USES   OF   THE    X-RAVS  453 

developed    ulcers   at   the   point   of    injection,    and   the   inguinal   glands 
became  soft  and  spongy. 

Florentine  and  Linaschi  injected  guinea  pigs  in  the  intraperitoneal 
region  with  a  culture  of  virulent  tubercle  bacilli.  The  tube  was  at  a 
distance  of  10-20  centimetres,  and  so  placed  that  the  rays  penetrated 
the  inoculated  part.  The  X-rayed  animals,  when  dissected,  showed 
many  fewer  tuberculous  nodules  than  the  control  guinea  pigs,  and  in  a 
second  set  of  experiments  the  tuberculous  nodules  had  disappeared 
altogether,  in  the  neighborhood  of  the  injection,  in  the  X-rayed  animals. 

Chief  Therapeutic  Uses  of  the  X-Ravs 

The  X-rays  as  a  therapeutic  agent  may  be  used  to  relieve  pain  and 
itching  in  certain  diseases,  to  remove  hair  for  cosmetic  reasons,  to  treat 
sycosis  and  favus  ;  to  remove  a  birthmark,  and,  what  is  most  important, 
to  cause  external  new  growths  to  heal.  These  rays  are  also  serviceable 
in  lupus — especially  lupus  vulgaris,  and  in  some  cases  of  eczema  and 
acne. 

The  mode  of  action  of  the  X-rays  when  they  give  relief  from  pain 
offers  an  inviting  field  for  physiological  study. 

For  further  discussion  of  therapeutic  uses,  see  Appendix. 


CHAPTER    XVII 

INTRODUCTION    TO    SURGERY 

The  X-rays  were  used  in  surgery,  first,  to  detect  certain  foreign 
bodies,  such  as  bullets  ;  and  second,  to  recognize  fractures.  With  the 
progress  of  time  each  of  these  applications  of  the  rays  has  been  carried 
out  more  carefully,  foreign  bodies  are  more  exactly  located,  and  frac- 
tures are  studied  with  more  thoroughness.  The  impression  prevails 
among  some  surgeons  that  the  two  applications  just  mentioned  are  still 
the  only  ways  in  which  the  X-ray  examinations  assist  in  surgery  ;  but 
this  impression  is  a  mistaken  one,  for  the  method  has  extended  beyond 
these  limits,  and  includes:  first,  the  large  subject  of  diseases  of  the  bone, 
as,  for  example,  tuberculosis  of  the  bone,  rickets,  tumors  and  abscesses 
of  the  bone,  sub-periosteal  abscess,  osteosarcoma,  osteomyelitis,  the 
study  of  the  bone  during  the  process  of  repair,  etc. ;  second,  congenital 
malformations  ;  third,  the  specialties  of  dental  and  orthopedic  surgery ; 
fourth,  the  detection  of  calculi.  This  method  has  shown  itself  of  service 
likewise  to  the  embryologist  and  the  anatomist  in  the  study  of  the  de- 
velopment of  the  skeleton  ^  from  the  earliest  stages,  and  in  the  study  of 
the  normal  joints.''^  An  exact  knowledge  of  the  latter  is  also  of  especial 
benefit  to  the  surgeon. 

The  surgical  use  of  the  X-rays  is  then"  in  a  stage  of  natural  develop- 
ment. It  is  evident  that  the  profession  appreciate  the  fact  that  we  now 
have  for  surgical  purposes  a  method  of  examination  which  is  harmless, 
and  useful  as  a  basis  for  diagnosis,  treatment,  and  prognosis,  and  one 
that  may  save  needless  operations.  The  criticisms  which  were  made  of 
it  in  the  early  days,  and  the  shortcomings  of  which  it  was  accused,  were 

^  "Atlas  der  normalen  u.  pathologischen  Anatomic  in  typ.  Roentgenbildern,"  Lambertz, 
Lucas  Grafe  &  Sillem,  Hamburg,  1900. 

-  E.  A.  Codman,  M.D.,  "  Experiments  on  the  Application  of  the  Roentgen  Rays  to  the 
Study  of  Anatomy," /<?«;-««/  of  Experimental  Medicine,  1898,  pp.  383-392;  and  Eugene  R. 
Corson,  .M.D.,  "  An  X-Ray  Study  of  the  Normal  Movements  of  the  Carpal  Bones  of  the  Wrist," 
Proceedings  of  the  Ass'n  Am.  Anat.,  December,  1898,  pp.  67-92. 

454 


INTRODUCTION    TO   SURGERY  455 

due  largely  to  the  difficulties  of  carrying  it  out,  and  especially  to  the 
want  of  familiarity  with  radiographs,  and  consequently,  as  was  natural, 
an  inability  to  read  and  interpret  what  they  showed.  This  new  method 
should  of  course  be  used  in  connection  with  other  methods  of  exami- 
nation. 

Size  of  Apparatus.  —  Since  the  extremities  are  more  easily  pene- 
trated by  the  rays  than  the  trunk,  a  less  powerful  exciter  for  the 
vacuum  tube  than  is  necessary  for  the  physician  will  answer  for  a 
great  deal  of  surgical  work.  Foreign  bodies  are  very  apt  to  be 
found  in  the  extremities,  as  needles,  bits  of  glass,  etc.,  get  into  the 
hands  and  feet  more  frequently  than  into  other  portions  of  the  body. 
Second,  an  examination  of  the  records  of  8361  cases  of  fractures  ad- 
mitted to  the  Boston  City  Hospital  during  fifteen  years,  exclusive  of 
those  treated  in  the  out-patient  department,  demonstrates  that  fifty-four 
per  cent  at  least  could  have  been  examined  with  a  machine  of  moderate 
power;  and  that  out  of  1537  fractures  treated  during  two  years  at  the 
out-patient  department,  sixty-nine  per  cent  could  have  been  examined 
also  with  a  machine  of  this  size.     (See  Table,  page  456.) 

These  statistics  in  regard  to  fractures,  together  with  the  fact  already 
mentioned  that  a  larger  proportion  of  foreign  bodies  are  found  in  the 
extremities  than  in  the  trunk,  indicate  that  in  all  probability  more  than 
one-half  of  the  surgical  cases  could  be  examined  with  a  comparatively 
small  and  inexpensive  machine.  By  this  I  do  not  mean  to  suggest 
that,  when  possible,  the  surgeon  should  not  have  the  best  apparatus, 
but  I  do  wish  to  indicate  that  good  work  can  be  accomplished  with 
inexpensive  apparatus,  although,  of  course,  the  latter  would  have  its 
limitations. 

Radiograph  and  Fluorescent  Screen.  —  The  radiograph  is  better 
adapted  to  the  surgeon  than  the  physician,  as  most  of  the  former's 
work  is  done  on  the  extremities,  whereas  the  physician  deals  more 
largely  with  the  thorax  ;  in  the  extremities  the  parts  are  at  rest ;  in 
the  trunk,  as  a  rule,  they  are  in  motion.  But,  as  will  be  seen  later, 
the  fluorescent  screen  is  also  helpful  to  the  surgeon  in  connection 
with  the  radiograph. 

Knowledge  of  Normal  Bones  and  Joints ;  Interpretation  of  X-Ray 
Photographs.  —  Before  the  surgeon  attempts  to  interpret  X-ray  photo- 
graphs of  abnormal  bones  or  joints,  he  should  famiharize  himself  with 
the  appearances  of  the  bones  and  joints  of  healthy  persons  of  various 
ages;    otherwise    he    may    not    infrequently    be    led    into    error.       For 


456     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

instance,  an  epiphyseal  line  in  a  child  may  be  mistaken  for  a  fracture. 
Likewise,  when  considering  a  given  photograph,  he  should  always  have 
at  hand  a  history  of  the  case. 

TABLE     (See  page  455) 

8361  Cases  of  Fractures  treated  in  the  Wards  of  the  Boston  City  Hospital 
IN  Fifteen  Years  previous  to  July,  1897 


A 

4504  cases  could  have  been  examined  with 
a  machine  of  moderate  power. 

Hand  — 

Fingers 275 

Thumb 53 

Metacarpal 65 

Carpal i 

Wrist 10 

Colles 314 

Forearm  — 

Both  bones 193 

Radius 120 

Ulna 70 

Elbow 96 

Leg  — 

Both  bones 1349 

Fibula 820 

Tibia 396 

Potts 304 

Ankle 9 

Foot  — 

Astragalus 41 

Metatarsal 143 

Os  calcis 45 

Tarsus 27 

Toe    .      .                .....  167 

Cuboid    ........  I 

Cuneiform i 

Phalanges 4 

4504 


B 

3857  cases  needed  a  more  powerful 
machine. 

Facial  Bones 22 

Jaw 202 

Nasal  bones 124 

Zygoma 6 

Skull 564 

Ribs 587 

Sternum       14 

Spine 159 

Coccyx     6 

Pelvis 89 

Humerus           65 

Shaft 313 

At  elbow  joint 103 

Head 6 

Anatomical  neck 62 

Surgical  neck 48 

Clavicle 232 

Scapula 51 

Femur 60    j 

Neck  .........  349    I 

Shaft 616    I 

Impacted 11     ! 

At  knee  ........  18 

Knee 150 

3857    , 


A  series  of  X-ray  photographs  of  the  skeleton,  and  especially  of  all 
the  joints  of  healthy  individuals,  would  be  very  helpful  in  every  hospital  i, 


INTRODUCTION    TO   SURGERY  457 

for  comparison  with  corresponding  parts  in  the  X-ray  photograph  of 
any  given  patient.^ 

Radiographs  are  sometimes  accused  of  being  deceptive,  but  very 
frequently  they  seem  to  be  deceptive  because  the  surgeon  has  not 
learned  to  interpret  them. 

Value  of  Negative.  — The  art  of  reading  the  negative  made  by  means 
of  the  X-rays  is  one  which  deserves  careful  study  especially  on  the  part 
of  the  surgeon  as  the  negative  often  shows,  particularly  one  of  calculi, 
more  than  the  print.  (See  Chapter  III,  page  96.)  It  also  saves  delay, 
although  if  Velox  paper  is  used,  the  time  necessary  to  make  a  print  is 
short. 

Two  or  More  Negatives  made.  —  If  the  negative  presents  only  a 
faint  shadow  its  import  may  be  variously  interpreted  ;  therefore  two 
negatives  at  least  should  be  made  and  carefully  compared,  and  unless 
the  appearances  seen  in  one  confirm  those  observed  in  the  other,  a  third 
should  be  made  ;  no  doubtful  appearance  that  lacks  confirmation  should 
be  used  as  a  basis  for  diagnosis. 

Further,  X-ray  negatives  or  photographs  may  be  misleading  because 
the  relative  position  of  the  part  to  be  photographed,  the  plate,  and  the 
tube  are  not  such  as  to  give  the  best  answers  to  the  questions  in  the 
mind  of  the  surgeon. 

Stereoscopic  pictures  aid  in  making  simpler  the  interpretation  of  some 
of  the  conditions  present,  those  about  the  elbow  and  ankle  joints  espe- 
cially. This  point  will  be  further  discussed  in  succeeding  chapters. 
Professors  Trowbridge,  Elihu  Thomson,  and  Girdwood  directed  atten- 
tion to  the  method  some  years  ago. 

Comparison  of  Well  and  Affected  Bone.  —  In  disease  of  the  bone  the 
immediate  comparison  of  the  well  and  the  affected  part  is  often  advanta- 
geous, and  to  this  end  it  is  desirable,  if  we  suspect  disease  of  the  bones 
of  one  leg,  for  example,  to  take  a  picture  of  both  legs  on  one  plate. 

Importance  of  Two  Views. —  Two  radiographs  of  a  given  injury  or 
foreign  body  are  often  necessary  for  diagnosis.  This  point  will  be 
discussed  in  more  detail  in  the  succeeding  chapters. 

Importance  of  Good  Negatives.  —  In  the  early  days  of  the  X-rays 
the  surgeon  was  obliged  to  accept  pictures  such  as  should  not  be  re- 
ceived to-day,  and  although   much  may  be  suggested  by  an  indifferent 

1  Since  this  was  written,  I  tin.l  that  Dr.  R.  JedHcka  has  made  radiographs  of  the  elbow 
joint;  Drs.  (i.  Krat/enstein  and  W.  Scheffer,  of  the  wrist  and  shoulder  joints.  Fortschritte 
a.  d.  Geb.  d.  A'oc-ntgeiistr.,  Erganzungsheft  4,  1900. 


45S     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

negative,  in  many  fractures,  for  example,  much  more  can  be  learned 
from  a  good  one,  and  X-ray  photographs  of  the  bones  should  be  care- 
fully made  with  a  good  apparatus  in  order  to  get  as  perfect  outlines  and 
details  as  possible.  When  X-ray  examinations  are  made  with  refer- 
ence to,  or  on  account  of,  a  suspicion  of  a  diseased  condition  of  the 
bone,  nothing  short  of  the  best  can  be  considered  in  estimating  the  ca- 
pabilities of  this  method.  In  many  cases,  in  order  that  the  photographer 
may  do  his  work  in  the  best  way,  it  must  be  done  under  the  direction  of 
the  surgeon.  Many  things  that  would  be  overlooked  in  a  poor  radio- 
graph show  distinctly  in  a  good  one,  and  it  takes  but  little  more  time  to 
obtain  a  good  picture  than  to  make  a  blurred  and  unsatisfactory  one. 

Swelling  about  a  Fracture  and  Swollen  Joints.  — When  there  is  con- 
siderable swelling  about  a  fracture,  or  if  the  joints  are  much  swollen,  it 
is  more  difficult  to  obtain  a  satisfactory  picture  than  when  there  is  no 
swelling,  for  two  reasons  :  first,  the  plate  must  be  farther  from  the  bone 
in  the  former  case ;  and,  second,  the  thicker  the  soft  parts  are  the  more 
obstruction  do  they  offer  to  the  rays.  For  example,  a  bone  which  is 
2.5  centimetres  in  diameter  at  the  wrist,  and  is  covered  by  soft  parts 
having  a  thickness  of  1.25  centimetres,  would  show  a  marked  contrast  to 
the  soft  tissue  in  an  X-ray  photograph  ;  but  if  such  a  part  were  swollen 
so  that  the  soft  tissues  were  3.7  centimetres  in  thickness,  the  difference 
between  the  amount  of  rays  absorbed  by  the  bones  and  the  tissue  would 
make  the  contrast  between  the  two  less  pronounced.  In  such  cases  as 
the  above,  or  when  photographing  the  hip,  better  results  may  be  looked 
for  when  a  tube  is  used  that  has  a  low  resistance,  and  when  the  plate  is 
given  a  long  exposure,  than  when  the  contrary  method  as  to  tubes  and 
exposure  is  employed.  For  soft  tissues,  tubes  with  low  resistance  should 
be  used,  because  greater  differentiation  is  obtained  by  them.  If  the  parts 
are  thick  much  energy  must  be  sent  through  the  tube. 

Bones  and  Soft  Tissues.  —  W^hen  a  radiograph  is  desired  of  the 
bones  and  soft  tissues,  the  exposure  cannot  always  be  readily  adapted 
for  both  conditions,  because  to  show  the  one  requires  a  longer  exposure 
and  a  tube  of  different  resistance  than  the  other.  The  length  of  the 
exposure,  as  in  ordinary  photographs,  must  be  adapted  to  the  amount 
of  light  which  the  plate  receives  from  the  desired  object. 

Sinus.  — The  extent  of  a  sinus  may  be  recognized  by  means  of  the 
X-rays,  by  injecting  into  it  a  paste  made  of  subnitrate  of  bismuth  ;  the 
paste  should  be  thin  enough  to  flow  easily.  It  may  be  injected  through 
a  piston  syringe. 


CHAPTER    XVIII 

DEVELOPMENT   OF   THE   SKELETON.      CONGENITAL    MALFORMATIONS. 

frontal  cavities,     muscle 
Development  of  the  Skeleton 

The  following  cut  is  given  to  show  how  well  the  osseous  portions  of 
the  skeleton  may  be  seen  even  during  foetal  life  ;  but  since  the  develop- 
ment of  the  skeleton  has  been  studied  and  discussed  with  great  care, 
and  beautiful  reproductions  of  X-ray  photographs  made  by  Dr.  Lam- 
bertz,^  it  is  superfluous  to  do  more  than  refer  the  reader  to  his  work  on 
this  subject. 

Epiphysis.  —  The  X-rays  are  of  assistance  in  pointing  out  delayed 
union  of  the  epiphyses,  and  when  we  are  familiar  with  the  appearances 


Fig.  241.     Foetus.      (Size  of  original.) 

to  be  expected  of  the  epiphyses  at  different  ages,  that  is  to  say,  when 
we  have  made  a  physiological  scale,  we  may  find  that  we  have  gained 
a  method  of  estimating  the  general  condition  of  younger  patients  in 
regard  to  their  development. 

'  "  Atlas  der  normalen  u.  path.  Anat.  in  typ.  Roentgenbildern,"  Lucas  Grafe  &  Sillem,  Ham- 
burg, 1900. 

459 


46o     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


I 


Fig.  242.     A.  P.     Boy  about  fourteen  years  old.     Epiphysis  of  radius. 


DEVPXOPMENT   OF   THE    SKELETON  461 

The  preceding  cut  shows  how  clearly  the  epiphyses  may  be  seen  in 
a  boy  about  fourteen  years  of  age.  The  patient,  A.  P.,  was  examined 
at  the  out-patient  department  of  the  Boston  City  Hospital. 

Epiphyseal  Lesions  in  Children.  —  Hitherto  our  knowledge  of  epiphys- 
eal lesions  has  only  been  approximately  correct,  but  accurate  informa- 
tion can  now  be  obtained  by  the  X-rays.  Poland'  showed,  as  early  as 
1896,  the  importance  of  obtaining  X-ray  photographs  of  certain  forms 
of  recent  complicated  injuries  to  the  epiphyses  in  children,  and  cited  a 
case  of  a  boy  seventeen  years  old,  where  the  X-ray  photograph  con- 
firmed the  diagnosis  of  a  lesion  in  the  distal  end  of  the  metacarpal  bone. 
His  book,  entitled  "Traumatic  Separation  of  the  Epiphyses,"  is  of  value 
to  any  one  who  desires  to  make  himself  familiar  with  this  subject. 

Corson  has  also  written  an  excellent  article  on  the  studv  of  the 
normal  membral  epiphyses  at  the  thirteenth  year.^ 

Disturbance  of  the  Development  of  the  Bones  in  Cretinism.  —  Hof- 
meister'^  has  published  an  interesting  and  instructive  article  on  this 
subject,  in  which  he  reports  at  some  length  the  case  of  a  girl  four  years 
old  who  appeared  like  a  child  of  a  year  and  a  half  old  only.  She  could 
not  speak,  but  cried  continually.  The  thyroid  gland  could  not  be  felt. 
The  extremities  were  myxedematous  and  very  much  thickened. 

The  X-ray  photographs  showed  that  the  bones,  although  normal  in 
shape,  were  strikingly  small  for  the  age  of  the  child.  In  almost  all  the 
long  bones  the  diaphysis  only  was  seen  ;  of  the  epiphysis  either  nothing, 
or  small  centres  of  ossification  only,  could  be  observed.  The  child 
improved  strikingly  when  given  thyroid  extract. 

Robert  von  VVyss*  has  made  an  interesting  investigation  of  the  de- 
velopment of  the  skeleton  in  cretins  and  cretinoids,  and  compared  it  with 
that  of  the  normal  individual.  He  examined  by  means  of  the  X-rays  30 
abnormal  persons,  24  of  whom  ranged  from  7  to  20  years  of  age,  and  6 
from  23  to  55  years  of  age.  In  connection  with  the  data  obtained  from 
radiographs  of  the  elbow,  hand,  knee,  etc.,  he  gives  the  personal  history 
so  far  as  he  has  been  able  to  obtain  it,  and  in  7  cases  belonging  to  two 
families,  the  family  history. 

'  "  Skiagraphy  as  an  Aid  to  the  Diagnosis  of  Epiphyseal  Lesions  of  Childhood,"  British 
Medical  Journal,  London,  1896,  Vol.  T,  \^.  620. 

-  Annah  of  Surger\\  1900,  pp.  621-647. 

•'  "  Uber  Storungen  des  Knochenwachstums  bei  Cretinismus,"  Fortschritte  auf  dem  GeHete 
der  Roenigenstrahlen,  1897-1898,  pp.  4-12. 

■* "  Beitrag  zur  Kenntnis  der  Entwickelung  des  Skelettes  von  Kretinen  und  Kretnioi- 
den,''  Fortschritie  a.  d.  Ge/>.  d   Roeutgeustr.,  B.  Ill,  1899-1900. 


462     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

From  a  careful  investigation  of  the  subject  he  draws  the  following 
conclusions  :  — 

1.  That  there  is  no  hint,  in  the  cretins  and  cretinoids  observed,  of 
premature  ossification,  or  synostosis  (he  mentions  that  premature  synos- 
tosis has  been  taught  for  forty  years). 

2.  That  there  is  a  delay  in  the  ossification  of  the  cartilaginous  parts 
of  the  skeleton,  in  the  cretins  and  cretinoids  who  are  at  the  age  of 
development  or  a  little  older  only,  as  shown  by  the  late  development 
of  the  centres  of  ossification  and  the  delayed  union  of  the  epiphyses. 

3.  The  delay  in  the  process  of  ossification  as  compared  with  the 
normal  individual  is  of  a. few  years'  duration  only,  as  a  rule,  judging  by 
the  macroscopic  investigation  and  the  X-ray  examination  ;  only  excep- 
tionally is  an  abnormal  condition  to  be  found  in  this  respect  after  the 
age  of  twenty-five. 

4.  The  bones  of  the  hand  are  the  latest  to  ossify. 

Ossification  of  the  Cartilage  of  the  Larynx.  —  Scheier,^  in  his  study 
of  the  larynx  by  means  of  the  X-rays,  found  in  all  the  cases  he  exam- 
ined that  the  ossification  began  at  the  end  of  the  second  decade.  He 
considers  that  this  ossification  must  be  looked  upon  as  a  normal  process 
that  begins  when  other  portions  of  the  skeleton  have  concluded  their 
growth.  He  also  found  that  the  ossification  advanced  from  point  to 
point  in  a  tolerably  regular  manner,  and  its  line  of  advance  was  differ- 
ent in  men  and  women. 

Congenital  Malformations 

It  is  not  infrequently  difficult  for  the  surgeon  to  decide  from  the 
data  obtained  by  the  ordinary  methods  of  examination  whether  or  not 
he  should  attempt  to  improve  the  condition  of  the  patient.  The  X-rays 
afford  the  surgeon  a  means  of  determining  the  exact  condition  of  the 
bones,  and,  if  an  operation  seems  desirable,  assist  him  to  plan  the  best 
method  of  procedure.  The  following  illustrations  show  how  readily  the 
distribution  of  the  bony  portion  of  the  hand  can  be  made  out :  — 

Deficiency  and  Arrested  Development  of  Bones.  —  Dr.  Lane  -  reports 
two  cases  of  deficiency  of  the  shaft  of  the  ulna,  treated  successfully  by 
the  insertion  of  a  rabbit's  femur.  He  gives  an  X-ray  photograph 
illustrative  of  the  operation. 

1  Forischritte  a.  d.  Geb.  d.  Roentgenstr .,  B.  I,  1897-1898,  p.  64. 

2  Trans.  Clin.  Soc,  London,  Vol.  XXXII,  1899,  p.  44. 


DEVELOPMENT  OF  THE  SKELETON 


463 


Fig.  243.     Congenital  malformation  of  hand. 

Dr.  Schorstein  ^  reports  a  case  of  congenital  absence  of  both  clav- 
icles, and  Dr.  Alfred  G.  Levy,^  a  case  of  arrested  development  of  the 
third  and  fourth  ribs.     These  cases  are  illustrated  by  radiographs. 

1  Lancet,  January  7,  1899,  p.  10.  -  British  Medical  Journal,  May  13,  1899,  p.   1 150. 


464     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

Spina  Bifida.  — In  this  disease  Dr.  Carl  Beck'  has  found  that  the 
radiograph  showed  whether  there  was  an  opening  in  the  spinal  column 
and  gave  some  indications  of  the  character  of  the  contents  of  the  sac. 


Fig.  244.      Congenital    malformation     of    right    thumi).      Mnn    tut-nty-fivc    years   old.       Patient   of 

Dr.  Gushing. 

Examination   of   Frontal    Cavities    by   the   Aid   of   the   X-Rays.  — 
Scheier  ^  indicates  the  usefulness  of  the  X-rays  in  this  direction.     For- 

1  New  York  Medical  Record,  August  13,  1898,  p.  231. 

2  Fortschritle  a.  d.  Geb.  d.  Roentgetislr.,  B.  I,  1897-1898. 


DEVELOPMENT   OF   THE    SKELETON  465 

merly  the  only  means  of  judging  whether  or  not  the  sound  reached  the 
sinus  frontahs  was  the  direction  it  had  taken  and  the  distance  it  had 
entered.  Now,  by  means  of  the  X-rays,  its  entrance  or  failure  to  enter 
can  be  definitely  settled.  In  some  cases  in  which  Scheier  used  the 
sound,  the  X-rays  showed  that  it  had  reached  the  cavity  easily,  and  its 
shadow  could  be  watched  on  the  screen  as  it  was  moved  about.  In 
other  cases  the  X-rays  showed  that  the  sound  had  not  reached  the 
frontal  cavity  as  Scheier  had  thought  from  the  direction  it  had  taken 
and  the  distance  it  had  entered.  He  found  the  screen  gave  clearer 
pictures  than  the  negative,  and  the  negative  than  the  print. 

Spiess  ^  has  also  done  some  work  in  this  direction,  and  considers 
that  all  danger  is  excluded  because  the  movements  of  the  instrument 
can  be  watched  on  the  fluorescent  screen.  He  also  thinks  that  by 
means  of  improved  instruments,  on  which  he  is  working,  the  frontal 
cavities  can  be  brought  into  better  communication  with  the  nose,  and 
all  the  sinuses  can  be  thoroughly  scraped.  He  considers  that  with 
better  instruments  the  rhinologist  can  treat  cases  of  empyema  of  the 
frontal  cavities  in  its  severest  form,  that  have  been  formerly  referred 
to  the  surgeon.  Further,  he  believes  that  with  the  use  of  the  X-rays 
the  practitioner  can  hardly  be  deceived  as  to  whether  or  not  a  frontal 
cavity  exists.  The  part  should  be  examined  from  both  the  right  and 
left  sides  with  the  screen,  and  if  the  question  is  not  clear  an  X-ray 
photograph  should  be  taken  with  the  face  in  profile,  and  also  with  the 
light  going  through  from  the  back  of  the  head  to  the  face. 

Muscle 

Myositis  Ossificans  Traumatica.  —  Frederick  Eve  ^  reports  a  case  in 
which  the  X-ray  photograph  showed  a  mass  in  front  of  the  femur 
that  had  an  ill-defined  outline.  This  osseous  mass  was  removed  by 
operation,  and  the  patient  did  well.  Dr.  Eve  remarks  that  the  diag- 
nosis would  have  been  impossible  without  the  X-ray  photograph  and 
exploration. 

X-ray  examinations  may  be  of  use  in  myositis  ossificans  progressiva. 

Myositis  Ossificans.  —  Dr.  de  la  Camp^  reports  a  case  of  so-called 
myositis  ossificans,  of  which  Virchow  published  an  account  in  the  Ber- 
liner klin.   WocJicnscJir.,  No.  32,  1894.     The  patient  during  the  previous 

1  Ibid.  -  Trans.  Clin.  Soc,  London,  1899,  xxxii,  p.  232. 

^  Fortschyittc  a.  d.  Geb.  d.  Koentgenstr.,  B.  I,  pp.   179-1  So 


466     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

four  years  had  had  no  further  marked  attacks  of  ossification,  nor  had 
his  condition  been  essentially  influenced,  so  that  clinically  he  remained 
the  same.  Virchow,  in  discussing  the  case,  considered  that  it  was  an 
exostosis  luxurians  rather  than  a  myositis  ossificans ;  that  the  ossifica- 
tion did  not  so  much  have  its  origin  in  the  muscles,  as  that  (to  use 
Virchow's  expression)  the  skeleton  had  a  contagious  effect  upon  its 
surroundings.  The  X-ray  photograph,  states  Dr.  de  la  Camp,  confirms 
this  view,  and  shows  that  the  most  marked  ossification  was  in  the  thorax 
where  the  muscles  and  skeleton  come  in  contact  with  each  other. 

Remy  and  Contremoulin  ^  report  that  by  the  aid  of  chemical  prepa- 
rations the  muscles,  ligaments,  and  tendons  of  dead  bodies,  both  of 
men  and  frogs,  could  be  seen  in  the  radiograph.  This  method  would 
be  useful  in  showing  the  anatomical  relations  of  soft  part. 

1  Electrical  Revieu<,  New  York,  April  14,  1S97. 


CHAPTER   XIX 

FRACTURES   AND    DISLOCATIONS 

The  X-rays  provide  a  more  accurate  and  detailed  picture  of  a  frac- 
ture than  can  be  had  in  any  other  way.  In  some  cases,  as  will  be  seen 
presently,  the  diagnosis  of  fracture  can  be  made  only  after  an  X-ray 
examination  ;  in  other  cases,  which  simulate  a  fracture,  the  X-rays  show 
that  none  exists.  In  severe  sprains,  where  the  foot,  for  instance,  is 
much  swollen,  it  may  be  difficult  without  the  rays  to  know  whether  or  not 
a  fracture  is  present.  Further,  the  X-rays  make  unnecessary  or  curtail 
the  painful  examination  of  a  swollen  and  sensitive  part,  and  it  is  not 
improbable  that  the  excellent  views  of  the  fractured  bones  which  may 
now  be  obtained  will  lead  to  improved  methods  of  treatment. 

Drs.  Ross  and  Wilbert,^  in  a  careful  study  of  500"^  fractures,  have 
shown  the  value  of  the  X-rays  in  the  diagnosis  and  during  treatment 
of  these  injuries.  The  article  is  illustrated  by  outUnes  of  various  frac- 
tures, and  by  a  diagram  showing  the  frequency  with  which  fractures 
occur  in  different  bones.  The  interesting  fact  is  pointed  out  that  of 
these  cases  349  were  fractures  of  some  portion  of  the  upper  extremity, 
and  1 5 1  of  the  lower.  Fractures  of  one  or  more  phalanges  were  found 
in  21  cases,  and  of  one  or  more  metacarpal  bones  in  51  cases.  It  is 
also  suggested  that  these  fractures,  as  well  as  those  of  the  metacarpal 
bones,  were  probably  not  recognized  in  the  past,  even  when  of  quite  an 
extensive  nature.  In  many  of  the  metacarpal  cases  patients  did  not 
apply  for  treatment  until  two  to  ten  days  after  the  accident ;  pain, 
especially  when  trying  to  use  the  hand,  was  severe.  The  writers  also 
show  that  injuries  of  the  lower  articulating  surface  of  the  humerus  are 
more  common  in  children  than  in  adults,  and  they  state  that  when  the 

1 "  Five  Hundred  Cases  of  Fractures  of  the  Extremities  verified  by  Radiographs,"  Philadel- 
phia Mouthly  Medical  Journal,  June,  1899. 

-  Since  this  was  written  Drs.  Ross  and  Wilbert  have  reported  on  a  second  series  of  tive 
hundred  cases  which  were  verified  by  radiographs,  Philadelphia  Medical  Journal,  1900,  VI, 
1241-1244. 

467 


468     THK    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

lon<;  bones  are  broken  at  or  near  the  middle,  the  Hne  of  fracture  is 
ai)t  to  be  more  transverse  than  oblique. 

C.  T.  Dent  ^  states  that  the  X-rays  have  modified  existing  views  as 
to  the  nature  of  fractures.  First,  they  are  nearly  always  more  or  less 
oblique  ;  and,  second,  longitudinal  splitting  has  occurred  more  often 
than  has  been  realized.  He  likewise  points  out  that  the  X-rays  enable 
the  surgeon  to  watch  the  process  of  union  in  oblique  fractures,  and  that 
thev  render  aid  by  indicating  to  him  how  long  a  rigid  apparatus  should 
be  worn. 

I  will  not  attempt,  in  the  space  at  my  disposal,  to  discuss  the  whole 
subject  of  X-ray  examinations  of  fractures  in  detail,  as  books  are  now 
written  on  radiographic  examinations  of  the  fracture  of  one  portion  of 
a  single  bone  ;  for  example,  works  by  Dr.  E.  Gallois  of  Lyons,  and  Dr. 
Fernand  Picard  of  Paris,  on  fractures  of  the  lower  end  of  the  radius ; 
but  will  present  a  few  cases  of  fractures,  the  radiographs  of  which  were 
made  chiefly  at  the  Boston  City  Hospital,  to  illustrate  the  ways  in 
which  the  X-rays  assist  in  this  field. 

Method  of  Examination  by  the  X-Rays.  —  The  methods  of  examina- 
tion have  been  considered  in  Chapter  HI,  but  will  be  further  discussed 
here  and  illustrated  by  X-ray  photographs. 

Exauiiuation  with  Fluorescent  Screen.  —  Before  taking  a  photograph 
of  a  dislocation  or  a  fracture  it  is  well  to  examine  the  given  part  first 
with  the  fluorescent  screen,  in  order  to  see  in  which  direction  the  view 
is  likely  to  be  the  most  instructive.  The  screen  may  show  the  fracture 
when  the  photograph  does  not,  but  such  a  case  is  rare.  After  the  ex- 
amination has  been  made  with  the  fluorescent  screen,  the  photographic 
plate  can  be  put  over  the  part  to  be  radiographed  and  the  exposure 
made  without  moving  the  patient. 

Examination  with  the  Radiograph.  —  The  radiograph  gi\-es  the  sur- 
geon a  good  basis  for  proper  treatment,  and  puts  him  in  a  position  to 
determine  what  is  most  judicious  for  the  individual  case.  X-ray  exami- 
nations not  only  enable  the  surgeon  to  aid  the  special  patient,  but  to 
become  a  better  practitioner  because  the  habit  of  thinking  out  a  new 
problem  is  encouraged. 

The  following  case  illustrates  the  importance  of  X-ray  examinations, 
and  shows  also  that  in  some  instances  radiographs  are  essential — that 
we  cannot  rely  upon  the  fluorescent  screen.     The  case  also  shows  that 

i"The  Value  of  .Skiagraphy  in  .Surgical  Cases,"  Practitioner,  London,  1898,  LX,  pp. 
123-136. 


FRACTURES   AND    DISLOCATIONS  469 

it  is  well  to  have  the  plate  rather  larger  than  would  be  necessary  to 
cover  the  supposed  site  of  the  injury. 

T.  D.  fell  a  few  feet  from  a  staging  and  injured  his  right  foot.  He 
went  directly  to  a  hospital  and  was  carefully  examined  by  the  usual 
methods.  No  injuries  were  found.  He  was  then  examined  with  the 
fluoroscope,  and  no  injuries  were  detected.  No  radiograph  was  made. 
The  patient  remained  three  days  in  the  hospital,  and  was  then  dis- 
charged with  his  foot  in  a  plaster  cast.  A  day  or  two  later  he  returned 
to  the  out-patient  department  of  the  hospital,  and  this  time  a  radiograph 
was  taken.  The  plate  used  was  large  enough  to  include  the  lower 
portion  of  the  tibia  and  fibula  as  well  as  the  foot,  and  the  radiograph 
showed  (see  Fig.  245)  a  fracture  of  both  bones  of  the  right  leg. 

Importance  of  Radiograph  from  Two  Points  of  View.  —  Sometimes 
one  photograph  will  answer,  but  it  is  best  to  take  two  from  different 
points  of  view.  It  is  quite  possible,  as  just  shown,  that  a  fracture  may 
escape  observation  by  the  fluorescent  screen,  or  even  with  a  single 
X-ray  photograph,  but  if  two  pictures  of  the  bone  are  taken,  the  chance 
of  not  finding  a  fracture,  if  one  exists,  is  very  small.  Suppose  one  of 
the  long  bones  to  have  been  fractured,  with  no  displacement,  but  simply 
a  crack  through  the  bone.  If  a  view  is  taken  looking  through  the 
crack  of  the  fracture,  it  will  be  easily  recognized  on  a  photographic 
plate.  If,  however,  the  view  is  taken  at  right  angles  to  this,  the  frac- 
ture may  escape  detection  even  by  an  X-ray  photograph.  When  there 
is  a  fracture  without  displacement  it  is  as  a  rule  not  recognized  by  an 
examination  with  the  fluorescent  screen. 

Stereoscopic  Pictures.  —  For  the  location  of  many  fractures  of  the 
bones  —  this  statement  applies  particularly  to  the  joints  —  and  of  the 
position  of  foreign  bodies,  a  so-called  stereoscopic  view  is  very  satis- 
factory. In  order  to  get  a  good  view  of  many  surgical  injuries  or  dis- 
eases of  the  bones  two  pictures  must  be  taken  from  different  points  of 
view,  as  already  suggested,  but  the  relation  of  the  parts  will  often  be 
still  more  clearly  indicated  if  these  two  views  are  stereoscopic  ones. 
To  carry  out  this  method  of  examination  the  tube  must  be  moved,  after 
the  first  exposure  has  been  made,  a  distance  of  6.2  centimetres,  and  a 
second  photograph  taken,  the  patient  remaining  in  the  same  position 
during  the  two  exposures.  After  the  negatives  have  been  developed 
the  photographs  must  be  mounted  stereoscopically.  They  are  then 
looked  at  with  the  stereoscope,  or,  with  practice,  with  the  eyes  alone. 
Now  that  we  have  a  reflecting  stereoscope  it  is  no  longer  necessary  to 


Fig.  245.    T.  D.     Fractures  recognized  only  by  radiograph. 


FRACTURES   AND    DISLOCATIONS 


471 


reduce  the  pictures  in  order  to  make  them  fit  into  a  small  stereoscope. 
Professor  Girdwood  has  suggested  and  used  the  reiiecting  stereoscope 
successfully. 

The  following  cut  shows  a  modification  of  the  Wheatstone  stereo- 
scope. The  radiographs  are  held  in  sliding  frames,  and  the  observer 
so  places  his  eyes  that  the  reflection  of  each  picture  is  seen  in  each  of 
the  two  mirrors  in  the  middle  of  the  apparatus. 


Fig.  246. 

Errors  to  be  avoided.  —  Two  errors  are  not  uncommon  when  making 
X-ray  examinations  of  bones.  The  first  occurs  only  in  patients  where 
the  epiphyseal  line  is  still  present ;  this  line  has  been  mistaken  for  a 
fracture,  hence  the  importance  of  familiarity  on  the  part  of  the  surgeon 
with  the  characteristics  of  the  bones  of  persons  of  different  ages  (see 
Chapter  XVII,  Introduction  to  Surgery,  page  455);  the  other  is  due  to 
the  reliance  placed  upon  one  photograph  for  the  determination  of  the 
presence  or  absence  of  a  fracture.  Two  photographs  should  be  taken, 
as  above  stated,  to  avoid  this  error,  the  direction  of  the  light  when  the 
first  view  is  taken  being  at  right  angles  to  its  direction  when  the  second 
photograph  is  made. 

Advantages  of  Permeable  Splints  and  Dressings.  —  Wooden  splints 
and   cotton   dressings  are  preferable  to  plaster,  and  to  dressings  that 


472     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


Soft  rubber  drainage  tube. 

Silver  wire. 

Going  from  left  to  right,  the 
needles  are  threaded  with 
catgut,  horsehair,  silkworm 
gut,  iron-dyed  silk,  and 
silk,  respectively. 


Fig.  247.     Radiograph  of: 

Tin. 

Plaster-of-paris  bandage  6  mm. 

thick. 
Aluminum  four  times  as  thick 

as  the  tin. 
Wooden    splint    3    mm.   thick. 
Mill  board  6  mm.  thick. 


Iodoform  bandage. 
Starch  bandage. 
Rubber  plaster. 
Corrosive  cotton. 
Cotton. 


FRACTURES   AND    DISLOCATIONS  473 

obstruct  the  rays,  whether  an  X-ray  photograph  is  to  be  taken  or  an 
examination  made  with  the  fluorescent  screen,  because  they  allow  the 
surgeon  to  see  the  position  of  the  parts,  and  learn  whether  it  has  been 
properly  set  without  removing  the  splints,  and  to  watch  the  process  of 
repair  going  on.  The  preceding  cut  illustrates  the  various  degrees  of 
obstruction  offered  to  the  X-rays  by  different  kinds  of  splints  and 
dressings,  and  by  buckles,  pins,  etc. 

The  following  cut  (Fig.  248,  fracture  of  both  bones  of  the  leg)  shows 
the  effect  of  iodoform  in  a  picture,  and  that  it  might  easily  be  mistaken 
for  a  foreign  body  (see  Chapter  III,  page  86).  It  is  so  opaque  that  in 
this  case  it  obscures  one  of  the  fractures. 

Position  of  Patient.  —  It  is  an  advantage,  generally  speaking,  to  have 
the  patient  lying  on  the  stretcher  when  a  photograph  of  a  fracture  is 
taken.  The  position  is  a  comfortable  one,  and  enables  the  patient  to 
keep  the  given  part  at  rest. 

Examination    of    Special    Bones    of    the    Body,    Illustrated    by 

Radiographs 

These  radiographs  largely  explain  themselves;  they  and  the  notes 
appended  indicate  or  demonstrate  such  points  as  the  following :  that 
X-ray  examinations  make  a  more  exact  diagnosis  possible  ;  they  may 
show  the  absence  of  a  fracture  where  by  the  ordinary  methods  one  was 
thought  to  be  present,  or  the  presence  of  a  fracture  that  had  been 
overlooked  by  the  ordinary  methods  —  this  fact  is  especially  the  case 
in  fractures  of  the  phalanges  and  metacarpal  bones  ;  if  there  is  a  frac- 
ture, they  show  its  site  and  character,  and  whether  or  not  the  parts  are 
in  good  position  ;  that  the  X-rays  are  useful  in  showing  us  cases  of 
fracture  where  there  is  much  swelling  and  where  palpation  is  difficult ; 
that  an  old  callus  may  be  seen,  but  not  a  recent  callus,  or  that  the 
latter  can  be  seen  only  indistinctly  ;  that  it  is  an  advantage  to  compare 
the  well  and  injured  extremity  on  the  same  plate;  that  thin  parts  are 
more  easily  radiographed  than  thick  parts  ;  that  it  is  important  to  take 
radiographs  of  a  fracture  from  two  points  of  view  ;  that  a  record  of  the 
position  of  the  tube  with  reference  to  the  plate  is  necessary  (see  Chapter 
III,  page  87),  and  of  the  relative  position  of  the  plate  and  the  part  to  be 
photographed. 

When  these  radiographs  were  taken,  the  tube  was  70  centimetres 
from  the  plate,  and,  as  a  rule,  opposite  the  fracture.      I  do  not  give  cuts 


474     'l^HE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

of    stereoscopic   pictures,   as   they   do   not   lend   themselves    readily   to 
demonstration  without  a  stereoscope. 


Fig.  248.  The  light  foreign  bodies  at  left  of  cut,  resembling  pieces  of  metal,  are  pieces  of  iodo- 
form. Both  bones  of  the  leg  have  been  fractured,  but  the  fracture  of  the  tibia  is  obscured  by  the 
iodoform.  (This  radiograph  was  taken  on  bromide  paper,  which  was  then  coated  with  oil,  and  silver 
prints  were  made  from  it.  In  this  cut  the  parts  that  would  be  dark  in  a  print  made  from  an  ordmary 
glass  negative  are  light ;  the  iodoform  obstructs  the  X-rays  and  casts  a  shadow  as  does  lead.) 


FRACTURES    AND    DISLOCATIONS  .  475 

Skull.  — If  a  fracture  of  the  skull  has  occurred,  or  is  suspected,  it  is 
well  first  to  examine  the  head  carefully  with  the  fluorescent  screen,  and 
to  follow  so  far  as  may  be  possible  the  outline  of  the  interior  as  well  as 
the  exterior  of  the  bones  of  the  cranium,  as  this  examination  may 
enable  the  practitioner  to  select  the  best  point  of  view  from  which  to 
take  the  photograph.  By  "  point  of  view  "  I  mean  the  best  position 
both  for  the  vacuum  tube  and  the  photographic  plate  with  reference  to 
the  part  of  which  a  photograph  is  desired.  If  the  fluorescent  screen 
gives  no  hint,  two  or  more  photographs  must  be  taken  so  that  the  part 
may  be  viewed  from  different  directions.     The  base  is  now  inaccessible. 

Much  ingenuity  may  be  exercised  in  devising  suitable  methods  for 
obtaining  photographs  of  special  parts  of  bones  of  the  face.  For  ex- 
ample, if  a  picture  is  desired  of  some  portion  of  the  jaw,  or  of  the  teeth, 
it  is  an  advantage  to  put  the  photographic  plate  inside  the  mouth,  in 
contact  with  the  part  to  be  photographed,  according  to  the  method 
devised  by  Dr.  Rollins  (see  chapter  on  Dental  Surgery,  page  606).  To 
make  this  arrangement  practicable  the  film  used  must  be  stiffened  by  a 
backing  of  wood  or  cardboard  and  wrapped  in  light-proof  paper,  and 
the  whole  must  be  covered  with  a  water-tight  cloth.  The  size  of  the 
film  must  be  adapted  to  the  part  of  which  a  picture  is  desired.  By  this 
method  the  photograph  may  be  taken  without  including  the  bones  on 
the  other  side  of  the  face,  as  would  be  necessary  were  the  film  on  the 
outside  of  the  cheek  and  the  tube  opposite  the  other  cheek,  and  thus  the 
picture  is  free  from  undesired  and  confusing  images. 

Spine.  —  In  photographing  the  spine  it  is  generally  best  to  make 
separate  pictures  of  the  cervical  and  dorsal  vertebrae,  and  perhaps  also 
of  the  lumbar  vertebrae.  A  good  photograph  of  several  of  the  first- 
mentioned  vertebrae  may  be  obtained  when  the  plate  is  put  on  the  side 
of  the  neck  with  the  light  opposite  to  it  on  the  other  side.  (See  Fig. 
68.)  The  outlines  of  this  portion  of  the  spine  can  also  be  seen  very 
well  on  the  fluorescent  screen.  When  a  photograph  is  desired  of  the 
dorsal  and  lumbar  vertebrae,  the  best  position  for  the  plate  is  under  the 
back,  the  patient  being  in  a  prone  position  on  the  stretcher.  In  this 
connection  the  following  case  reported  by  Noble  Smith  ^  is  interesting, 
as  it  shows  the  usefulness  of  the  X-rays  in  injuries  to  the  spine.  The 
patient  fell  eighty  feet,  and  some  weeks  after  the  fall  suffered  from 
pain  and  stiffness  of  the  neck.  An  examination  showed  an  angular  bend 
between  the  fifth  and  sixth  cervical  vertebrae,  and  an  X-ray  photograph 

1  Medical  Press  aud  Cireular,  London,  1900,  N.  S.  LXIX,  p.  240. 


Fig.  249.  Patient  of  Dr.  Lothrop.  Fracture  of  surgical  neck  of  right  humerus  just  below  tuber- 
osities. Radiograph  shows  site  and  character  of  the  fracture.  The  radiograph  was  taken  outside 
of  the  bandages  after  the  fracture  was  put  up. 


Fig.  250.     Fracture  of  surgical  neck  of  tlie  right  humerus  of  a  girl  nine  years  old. 


Fig.  251.      Healed  fracture  of  lower  third  of  humerus  in  a  girl  ten  years  old.      Callus  shows  clearly. 


FRACTURES   AND    DISLOCATIONS 


479 


clearly  indicated  a  partial  displacement  between  them.     The  patient  was 
placed   under  ether  and   firm   extension    made   upon  the  head.      Some 


Fig.  252.     Patient  of  Dr.  John  C.  Munro.     Fracture  of  lower  end  of  humerus  and  olecranon. 


Fig.  253.  Patient  of  Dr.  Paul  Thomdike.  Fracture  of  olecranon  and  head  of  ulna  of  a  man 
seventy-six  years  old.  Crepitus;  effusion  into  the  joint ;  motion  at  elbow  caused  extreme  pain.  X-ray 
photograph  taken  a  week  after  the  accident. 


FRACTURES   AND    DISLOCATIONS 


481 


adhesions  gave  way,  and  after  more  force  was  applied,  a  slight  gliding 
movement  was  felt  in  the  neck,  and  it  was  then  found  that  the  vertebrae 
occupied  their  natural  straight  position.  Since  this  operation  the 
patient  has  remained  perfectly  well. 

Shoulder.  — X-ray  photographs  are  of  great  service  in  determining 
the  exact  site  of  a  fracture  of  the  humerus,  especially  when  it  occurs 


Fig.  254.     Fracture  of  ulna  caused  by  a  circular  saw;  ends  of  ulna  approximated  by  silver  wire. 

Patient  of  Dr.  Post. 


near  the  joint  of  the  shoulder.  Two  photographs  of  this  fracture  are 
frequently  necessary  in  order  to  obtain  all  the  information  desired  ;  one 
should  be  taken  with  the  plate  on  the  front,  and  the  other  with  the  plate 
on  the  back,  of  the  shoulder.  The  shoulder  is  often  so  enveloped  in 
the  dressing  or  splint  that  the  plate  cannot  be  brought  near  the  bone, 
and  in  such  a  case  the  tube  must  be  placed  at  a  greater  distance  from 
2  I 


482     THE   ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

the  patient  than  would  otherwise  be  desirable,  in  order  to  avoid  distor- 
tion and  to  obtain  good  definition.  In  photographing  the  parts  about 
the  shoulder  joint,  including  the  shoulder  itself  and  the  clavicle,  it  is 
usually    best    to  put  the  plate  nearest  the  part  of  which  a  picture  is 


Fig.  255.  Ununited  fracture  and  necrosis  ni  tne  fjone.  j.  \\".,  twenty-five  years  old.  Fell  from 
a  house  at  a  height  of  about  forty  feet,  October  26,  1899,  and  injured  his  left  arm.  The  radius  was 
found  on  examination  to  be  fractured  at  about  the  middle,  and  there  was  a  backward  dislocation  of 
the  elbow.  December  18,  necrosis  of  bone  for  about  3.5  centimetres.  The  X-ray  photograph  from 
which  this  cut  was  made  was  taken  March  28,  1900. 


FRACTURES   AND    DISLOCATIONS 


483 


Fig.  256.    Supposed  fracture  of  radius ;  radiograph  indicates  that  none  exists. 


f 


At— ^     -  ^gg.- 


FlG.  257.     Simon  D.     Patient  of  Dr.  Monks.     Healed  fracture  of  left  radius  before  operation. 


FRACTURES   AND    DISLOCATIONS 


485 


desired,  and  to  place  the  tube  on  the  opposite  side,  at  a  considerable 
distance  from  the  patient,  in  order  to  get  good  definition  and  avoid  the 
distortion  mentioned  above. 


Fk;.  2:;8.     Simon  D.     Patient  of  Dr.  Monks.     Taken  two  months  after  operation ;  shows  callus. 


Elbow. — The  elbow-joint  is  somewhat  complicated,  and  it  is  often 
difficult  to  interpret  X-ray  photographs  of  fractures  of  this  joint.  As 
a  rule,  therefore,  two  pictures  at  least  are  necessary,  one  taken  from  an 
antero-posterior  and  one  from  a  lateral  point  of  view.     The  stereoscopic 


Fig.  259.  Frederick  F.,  twenty-five  years  old;  carpenter.  Entered  hospital  November  23.  1900. 
Patient  of  Dr.  George  H.  Monks.  Open  fracture  of  the  radius.  The  right  Jorearm  at  its  distal  end 
presents  an  open,  extensive,  comminuted  fracture.  December  7th,  position  by  mspection  and  by 
X-rays  good.     Antero-posterior  view. 

The  small  metal  washer  indicates  the  point  opposite  which  the  target  of  the  vacuum  tube  was 
placed.     The  tube  was  at  a  distance  of  70  centimetres. 


FRACTURES   AND    DISLOCATIONS 


487 


method  is  also  of  assistance  liere.      If  the  elbow  is  surrounded  by  a  thick 
bandage,  or  if  it  cannot  be  straightened,  it  is  difficult  to  get  a  plate  of 


Fig.  260.     Frederick  F.     Lateral  view. 


488     THE    ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 

ordinary  size  near  enough  to  the  inside  of  the  elbow  to  get  a  good 
picture ;  therefore  in  such  a  case  rather  a  small  plate  should  be  used. 
The  tube  should  be  at  a  considerable  distance,  about  70  centimetres  away, 
as  when  a  shoulder  is  taken,  and  for  the  same  reason. 

Radius,  Ulna,  and  Wrist.  —  Two  photographs  should  be  taken  of  an 
arm  fractured  near  the  wrist,  or  of  a  fractured  wrist ;  one  from  an  antero- 
posterior and  the  other  from  a  lateral  point  of  view ;  a  stereoscopic  pic- 
ture of  the  wrist  joint  and  the  end  of  the  radius  is  often  instructive. 


Fig.  261.  James  C,  age  not  given  in  records.  Out-patient  department  of  the  Boston  City  Hos- 
pital. Diagnosis,  sprained  wrist.  X-ray  photograph  showed  fracture  of  radius  2.5  centimetres  above 
the  articular  surface. 

There  is  no  fracture  of  the  ulna;  the  line  seen  on  the  ulna  is  the  epiphyseal  line.  Such  lines 
have  been  mistaken  for  fractures. 

Supposed  Fracture  of  Radius.  —  The  cut  (see  Fig.  256)  shows  no 
fracture  of  the  radius,  and  probably  none  exists,  where  by  the  ordinary 
methods  a  fracture  was  thought  to  be  present. 

Radiographs  as  a  Guide  to  Treatment.  —  Simon  D.,  twenty-seven 
years  old,  entered  the  hospital  April  18,  1899,  patient  of  Dr.  Monks. 
The  patient  fractured  his  left  radius  and  both  femurs  by  falling  about 
forty   feet  in   an   elevator.      About  two   months   and   a   half   later   the 


FRACTURES   AND    DISLOCATIONS 


489 


X-ray  photograph  was  taken,  which  showed  bowing  of  the  radius  and 
supination  limited  over  two-thirds.  The  end  of  the  left  radius  had 
grown  to  the  ulna.     (See  page  484.) 

To  improve  rotation  an  operation  was  performed  by  Dr.  Monks  on 
the  radius.     An  incision  was  made  over  the  site  of  the  fracture  and  the 


Fig.  262.  Left  colles  fracture.  Patient  of  Dr.  J.  B.  Blake.  Tw  o  views  of  a  fracture  of  the  wrist 
should  always  be  taken  —  one  from  front  to  back  and  the  other  from  side  to  side  —  and  this  is  now 
done  as  a  matter  of  routine  at  the  Boston  City  Hospital. 


490 


THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


old  callus  was  divided  with  a  chisel.  Adhesions  with  the  idna  were 
broken  away,  and  the  smallest  possible  piece  was  sawed  off  of  each  end 
of  the  radius  to  square  them.  The  ends  of  the  radius  were  then  drilled 
and  wired  with  silver  wire,  as  seen  in  the  radiograph,  taken  about  two 
months  after  this  operation  was  done.     (See  Fig.  258.) 


Fig.  263.  Gerlrude  F.,  tuenty-three  years  old.  Enicicil  lii.>|jital  Xovember  8,  1900.  Patient! 
of  Dr.  Monks.  Diagnosis  :  fracture  of  left  radius.  Fell  down  a  flight  of  stairs,  injuring  both  wrists; 
under  ether ;  crepitus ;  abnormal  mobility.  Radiograph  also  shows  fracture  of  the  tip  of  the  styloid 
process  of  the  ulna.     Antero-posterior  view. 

New  and  Old  Callus  about  a  Fracture.  —  A  callus  which  has  formed'- 
recently  about  a  fracture  does  not  show  in  an  X-ray  photograph,  but 
later,  when  inorganic  salts  are  present,  it  gives  a  well-marked  outline. 
The  cases  (see  Figs.  258  and  283)  are  illustrative. 


FRACTURES   AND    DISLOCATIONS 


491 


Fig.  264.     Gertrude  F.     Fracture  of  the  left  radius  and  the  tip  of  the  st\loid  process  of  the  ulna. 

Lateral  view. 


Fracture  of  Phalanges  and  Metacarpal  Bones  liable  to  be  overlooked  with- 
out X-Rays.  —  These  fractures  are  apt  to  be  overlooked  by  the  ordinary 
methods,  as  already  indicated  on  page  467,  but  are  seen  by  the  X-rays. 


492     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 


Fig.  265.     Mrs.  H.     Fracture  of  third  metacarpal  bone.     Antero-pnsterior  view. 


The  preceding  and  the  three  following  cuts  (and  the  next  case  given, 
"  Stave  of  the  Thumb  ")  show  how  easily  this  overlooking  may  occur :  — 

The  So-called  "Stave  of  the  Thumb"  Fracture.  —  Beatson  ^  reports 
the  case  of  a  surgeon  who  had  fallen,  during  rough  weather,  on  a 
steamer,  and  thought  he  had  merely  bruised  his  thumb  severely ; 
but  the  recovery  was  so  slow  that  si.xteen  days  after  the  accident  he 
consulted  the  reporter  of  this  case.  Beatson  thought  he  could  detect 
some  crepitus,  and  an  X-ray  photograph  confirmed  the  existence  of  a 
fracture  at  the  base  of  the  metacarpal  bone.  The  leading  feature  of 
this  fracture  Beatson  describes  as  the  "  inability  to  oppose  the  thumb 
to  the  index  finger."  This  inability  interfered  with  the  use  of  the  hand 
in  many  ways.  An  X-ray  photograph  taken  two  and  a  half  weeks 
after  treatment  showed  satisfactory  results,  and  later  all  disablement 
disappeared.  Beatson  concludes  by  recommending  that  all  "  sprains  of 
the  right  thumb  "  be  X-rayed,  for  otherwise  a  fracture  may  be  overlooked. 

Pelvis.  — ■  This  part  of  the  skeleton  is  taken  up  in  the  chapter  on  the 
Abdomen. 

^  British  Medical  Joiti-nal,  May  5,  1900. 


FRACTURES   AND    DISLOCATIONS 


493 


Hip.  —  There  are  special  difficulties  to  be  encountered  in  obtaining 
an  X-ray  photograph  of  a  hip-joint,  particularly  in  stout  patients ;  first, 
because  the  difference  in  the  amount  of  rays  absorbed  by  the  thick 
tissues  surrounding  the  bone  and  the  bone  itself  is  not  so  great  as  in 
the  more  superficial  joints,  and  therefore  the  bone  does  not  stand  out  as 
well  in  the  photograph  as  is  the  case  when  the  joints  lie  nearer  the  sur- 
face ;  second,  because  the  bone  is  at  a  considerable   distance  from  the 


Fig.  266.     Fracture  of  phalanx  of  second   finger  of  right  hand;  no  displacement;   little  mobility. 
Corresponding  phalanx  of  first  finger  shown  for  comparison. 


plate  ;  third,  if  the  hip-joint  is  tuberculous  the  contrast  between  the 
bone  and  the  soft  tissues  is  not  so  good  as  when  the  joint  is  normal, 
unless  the  patient  is  very  much  emaciated,  because  a  tuberculous  bone 
is  more  transparent  to  the  rays  than  a  normal  bone,  and  therefore  the 
tuberculous  bone  and  the  soft  tissues  are  more  nearly  alike  in  regard  to 
the  obstruction  they  offer  to  the  rays. 

In  photographing  a  fractured  hip  it  is  often  well  to  place  the  patient 


Fig.  267.     Fracture  of  fourth  metacarpal  bone  of  left  hand,  indicated  by  arrow. 


FRACTURES   AND    DISLOCATIONS 


495 


on  his  back  and  the  tube  underneath  him,  not  in  the  median  hne,  but 
under  the  point  it  is  desired  to  photograph.  If  the  patient  is  thin,  the 
plate  is  placed  to  advantage  over  the  front  of  the  hip ;  but  if  stout,  it  is 
better  to  put  it  under  the  patient  because  the  large  abdomen  makes  it 
difficult  to  get  the  plate  as  near  the  front  of  the  hip  as  is  desirable;  or 


Fig.  268.     Fracture  of  fifth  metacarpal  of  hand.     Patient  of  Dr.  F.  B.  Lund. 


the  hips  and  the  femurs  may  be  placed  in  the  same  position  and  the 
tube  be  put  opposite  the  median  Hne,  as  this  arrangement  gives  an 
opportunity  of  comparing  one  hip  with  another. 

Thigh.  —  In  fractures  of  the  femur,  or  upper  and  lower  part  of  the 
tibia  and  fibula,  two  photographs  are  necessary,  as  in  the  case  of  the 


496     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

elbow-joint,  one  taken  from  an  antero-posterior,  and  one  from  a  lateral 
point  of  view. 


Fig.  269.    J.  VV.     Fracture  of  thumb. 


FRACTURES   AND    DISLOCATIONS 


497 


Importance  of  Two  Views.  — The  following  case  shows  the  advantage 
of  taking  two  views  of  a  fracture.  The  first  radiograph  was  made  from  a 
lateral  point  of  view  and  showed  no  fracture  (see  Fig.  270);  the  second 
radiograph  was  taken  from  an  antero-posterior  direction  and  showed 
fracture.     (See  Fig.  271.) 


Fig.  270.     Fracture  of  left  femur 
2  K 


Lateral  view ;  no  fracture  shown.     Patient  of  Dr.  M.  F.  Gavin. 


498    THE   ROENTGEN    K\YS   IN    I^IEDICINE   AND   SURGERY 


Fig.  271.    Fracture  of  left  femur,  antero-posterior  view ;  fracture  sho\\-n.     Patient  of  Dr.  Gavin. 


FRACTURES  AND   DISLOCATIONS 


499 


SHHL 


j  I  a;.  272.     Patient  of  Dr.  W.  P.  Bolles.     Fracture  of  patella  of  a  man  fifty-four  yeaxs  old.     X-ray 

^  photograph  taken  the  following  day.     The  cut  shows  the  position  after  the  bandage  had  been  applied 
to  the  approximate  parts.    The  depression  of  the  fiesh  above  and  below  the  patella  shows  the  position 
.  of  the  bandage. 

Knee.  —  When  a  photograph  of  the  knee  is  desired,  two  views  are 
j  better  than  one.  In  nearly  all  cases,  if  only  one  picture  is  made,  it  is 
I  best  to  put  the  plate  either  on  the  inside  or  outside  of  the  knee  rather 
;  than  under  or  above  it. 


Fig.  273.    Fracture  of  patella;  front  view  ;  plate  over  patella;  bones  wired  by 
Dr.  F.  S.  Watson's  method. 


FRACTURES   AND    DISLOCATIONS 


501 


Fig.  274.     Fracture  of  patella  ;   side  view. 


Patient  of«Dr.  F.  S.  Watson. 


Leg  and  Ankle.  —  In  fractures  of  the  bones  of  the  leg  an  antero- 
posterior view  is  usually  the  better,  but  of  the  ankle  a  side  view  is  the 


502     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


Fig.  275.  John  vS.,  Uvc  xcars  oui.  I'aucin  01  J)r.  Aiunrd.  -November  13,  1900,  tripped  over 
Stick  in  room  and  was  afterwards  unable  to  stand.  Sent  to  the  hospital  on  the  same  day.  Left  leg 
at  junction  of  middle  and  lower  third  presents  a  deformity;  considerable  swelling;  no  crepitus  ;  very 
sensitive  to  touch.  X-ra3's  showed  a  fracture  of  the  tibia ;  fibula  intact.  Radiographs  taken  on 
day  of  entrance,  November  13,  1900.  Plate  placed  on  inside  of  leg.  Tube  was  opposite  metal  washer. 
This  case  shows  the  importance  of  two  views. 


FRACTURES   AND    DISLOCATIONS 


503 


better,  and  easier  to  take.     Two  views  of  the  ankle  and  leg,  an  antero- 
posterior and  a  lateral  one,  as  in  the  case  of  the  elbow,  will  often  reveal 


Fig.  276.     John  S.     Plate  placed  on  front  of  leg.     This  view  does  not  show  iracture,  but  it  is  clearly 
seen  in  the  lateral  view  (see  preceding  figure). 


Fig.  277.  Patient  of  Dr.  Gushing.  Fracture  of  lower  end  of  fibula.  In  this  case,  of  a  woman 
thirty  years  old,  the  left  ankle  was  much  swollen,  and  there  was  also  much  swelling  of  the  leg  and 
foot;  tenderness  began  6  centimetres  above  the  tip  of  the  external  malleolus.  Careful  examination 
by  the  usual  methods  was  not  possible  on  account  of  oedema  and  swelling.  Two  X-ray  photographs 
were  taken.  The  one  from  the  antero-posterior  view  showed  no  fracture;  the  lateral  view  showed 
fracture. 


FRACTURES   AND    DISLOCATIONS 


505 


more  clearly  the  exact  condition  of  the  bones  than  can  be  obtained  in  any- 
other  way.     Stereoscopic  pictures  are  also  excellent. 

Importance  of  Two  Views.  —  The  following  case(Hke  John  S.,  Figs. 
275,  276)   illustrates  the  importance  of  two  views  :  — 


Fig.  278.     William  A.     Fracture  of  both  bones  of  the  leg.     Antero-posterior  view. 


William  A.,  nine  years  old,  a  patient  of   Dr.   H.  W.  Gushing,  at- 
tempted to  climb  on  to  a  truck ;  caught  his  foot  between  the  spokes  of  the 


5o6    THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


Fig.  279.    William  A.     Lateral  view. 


wheel,  and  injured  his  right  leg.     There  was  apparently  an  oblique  frac- 
ture of  both  bones  of  the  leg.      About  ten  davs  later  two  X-ray  pictures 


F^ 


Fig.  280.  John  C,  ten  years  old.  Patient  of  Dr.  W.  P.  Bolles.  While  coastiiii;  ran  into  curbing, 
injuring  left  leg.  Two  radiographs  are  given,  which  show  a  separation  of  the  epiphysis  at  the  lower 
end  of  the  tibia,  and  the  fibrous  fracture  of  the  fibula.    Anlero-posterior  view. 


Fig.  281.     John  C.     Lateral  vi. 


Fig.  282.  James  H.G.,  thirty-nine  years  old.  Entered  hospital  November  30,  1900.  Patient  of 
Dr.  Munro.  The  patient  was  thrown  from  his  seat  while  driving  a  learn  and  fractured  both  bones  in 
the  middle  third  of  the  right  leg  on  November  30,  1900.  Swelling  and  crepitus.  Radiograph  made 
December  i,  1900,  which  shows  the  fracture  talcen  after  the  splints  and  bandages  had  been  put  on. 


5IO     THE   ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

were  taken,  one  from  an  antero-posterior,  and  the  other  from  a  lateral 
point  of  view.  In  the  former  view  especially  the  fracture  of  both 
bones  of  the  leg  is  clearly  seen. 


Fig.  283.    J.  F.  S.     Fracture   of  lower   end  of  tibia   and   longitudinal   split   in    fibula.     Patient   of 
Dr.  Watson.     Callus  felt  distinctly,  but  did  not  show  in  the  radiograph. 

Fracture  of  Lower  End  of   Tibia  and  Longitudinal  Split  in  Fibula; 
New  Callus  not  shown  by  X-Rays.  —  J.  F.  S.,  a  man  forty-five  years  old, 


Fig.  284.  Michael  M.,  sixty-one  years  old.  Entered  the  Boston  City  Hospital  January  11,  1899. 
Patient  of  Dr.  Watson.  While  walking  along  the  street,  slipped  on  the  ice  and  fell  to  the  ground. 
The  left  leg  showed,  5  centimetres  above  the  internal  malleolus,  an  oblique  fracture  of  the  tibia. 
The  left  fibula  appeared  also  to  be  broken.  Radiograph  taken  March  25,  1899,  showed  clearly  a 
fracture  of  both  tibia  and  fibula.     The  patient  was  discharged  with  good  union  April  26. 


Fig.  285.  Patient  of  Dr.  dishing.  Fracture  of  tibia  and  apparently  of  fibula,  that  of  the  fibula 
being  slightly  higher  tiian  that  of  the  tibia.  An  X-ray  photograph  was  taken  from  an  antero-posterior 
point  of  view,  \vhich  showed  the  fracture  of  the  tibia,  and  that  there  was  probably  no  fracture  of  the 
fibula.  The  injured  leg  shown  in  this  cut  was  taken  on  the  same  plate  with  the  uninjured  leg.  The 
patient  was  a  boy  three  and  a  lialf  years  old,  who  fell  about  twenty  feet  from  a  second-story  window. 


FRACTURES   AND    DISLOCATIONS 


513 


FIG.  286.     Uninjured  leg.     Taken  on  same  plate  with  the  injured  leg  shown  in  preceding  cut. 


514     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


I 


Fig.  287. 


Fracture  of  the  tibia  of  a  boy  six  years  old.     A  wheel  passed  over  the  left  leg 
of  Dr.  J.  C.  Munro.    Taken  on  same  plate  with  following  figure. 


Patient 


FRACTURES   AND    DISLOCATIONS 


515 


Fig.  288.     Boy  six  years  old.     Uninjured  leg.     Taken  on  same  plate  with  preceding  figure. 


Fig.  289.  Patient  of  Dr.  M.  F.  Gavin.  Fiacture  of  both  bones  of  the  leg  and  callus.  Two 
years  later  patient  fractured  both  bones  of  the  other  leg.  (See  Fig.  290.)  These  cuts  are  made  from 
a  large  negative  on  which  both  legs  were  radiographed  together. 


Fig.  290.  Patient  of  Dr.  Gavin.  Fracture  of  both  bones  of  leg.  Recent  fracture;  details 
of  fibula  less  clearly  seen  than  in  that  of  the  other  leg,  although  both  legs  were  taken  on  the  same 
plate.  One  illustrates  how  clearlv  the  bones  show  when  the  soft  tissues  ate  in  normal  condition,  and 
the  other  how  much  less  clear  they  appear  when  the  tissues  about  them  are  inflamed. 


5l8    THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


Fig.  291.  Patient  of  Dr.  Bolles.  Fracture  of  both  bones  of  the  leg.  WilHam  T.,  thirty-two  years 
old,  while  dancing  at  a  theatre,  twisted  his  right  foot,  heard  the  bone  snap,  and  fell  on  the  stage.  The 
X-ray  photograph  was  taken  si.x  days  later.  This  cut  shows  well  the  character  of  a  fracture  due  to 
torsion. 


FRACTURES   AND    DISLOCATIONS 


519 


entered  the  hospital  December  16,  1899.  Patient  of  Dr.  Watson.  On 
this  day  a  bale  weighing  two  hundred  pounds  fell  on  the  outer  side  of 
his  leg.     There   was  considerable  swelling  and  crepitus.     On  January 


Fig.  292.  Patient  ul  Di.  Cu^hing.  Fracture  of  both  bones  of  the  leg  of  a  man  iwmtv  \-.mis  <>\d, 
who  was  kicked  by  a  horse.  X-ray  photograph  was  taken  three  days  after  the  accident.  Nu  callus 
to  be  seen.  The  character  of  a  fracture  caused  by  a  heavy,  sharp  blow  is  seen  in  this  cut.  Compare 
with  preceding  cut,  of  a  fracture  caused  by  torsion. 

13,  1900,  a  large  callus  was  felt.  An  X-ray  photograph  (Fig.  283) 
was  taken  on  this  day,  which  showed  no  trace  of  the  callus,  although  it 
was  apparent  to  the  touch.  Compare  the  cut  (Fig.  283)  with  Fig.  258, 
which  shows  an  old  callus. 


FRACTURES   AND    DISLOCATIONS 


521 


Fig.  294.     Fracture  of  epiphysis.     R  indicates  the  point  opposite  which  the  lighi  wa^  placed  and 

that  it  was  the  right  leg. 


522 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


Absence  of  Fracture  indicated  by  X-Rays ;  Fracture  by  Ordinary 
Methods.  —  The  cut  (Fig.  285)  shows  that  there  was  a  fracture  of  the 
tibia,  but  probably  none  of  the  fibula,  as  had  been  supposed  before  the 
radiograph  was  made.  Cuts  285  and  286  illustrate  the  method  of  taking 
well  and  injured  leg  on  same  plate,  for  comparison  :  — 

Bowed  Leg  mistaken  for  Fracture.  —  Noble  Smith  ^  cites  a  case  of 
a  child  two  and  a  half  years  old  who  was  thought  to  have  bowed  legs. 
He  noticed,  however,  that  only  one  leg  was  affected,  and  that  the  inner 
malleolus  was  higher  than  natural,  and  that  the  child  felt  pain  if  the 
limb  were  touched.  He  therefore  took  a  radiograph,  which  showed  a 
fracture  of  the  tibia  4  centimetres  above  the  ankle-joint.  The  bone 
was  cut  down  upon  and  straightened,  and  the  child  made  a  good 
recovery. 

Advantage  of  comparing  Injured  and  Uninjured  Leg.  —  Cuts  287 
and  288  also  show  the  advantage  of  taking  a  picture  of  both  legs  in 
order  to  compare  the  injured  and  uninjured  one :  — 

Tarsus.  —  For  examining  the  bones  of  the  tarsus  the  tube  must  be 
placed  according  to  the  special  bones  that  it  is  desired  to  photograph. 

X-Rays  show  Cause  of  Chronic  Swelling  of  Foot.  —  The  chronic  swell- 
ing of  the  foot  which  arises  from  slight  sudden  blows,  from  a  rifle  butt, 
for  instance,  has  heretofore  been  looked  upon  as  due  to  an  inflamed  con- 
dition of  the  soft  parts,  tendons,  joints,  etc. ;  but  Freund  ^  states  that  the 
X-rays  show  it  is  really  due  to  the  fracture  of  one  of  the  metatarsal 
bones. 

There  is  a  saying  that  "  a  bad  sprain  is  worse  than  a  broken  bone," 
but  a  new  light  is  thrown  on  this  adage  by  X-ray  examinations,  as  they 
show  that  fractures  may  be  present  when  they  are  not  recognized  by 
the  older  methods,  and  therefore  that  the  inflammation  and  pain  which 
they  produce  are  attributed  to  other  causes.  The  saying,  with  our  pres- 
ent knowledge,  should  for  some  cases  be  amended. 

Foot.  —  The  metatarsal  bones  and  phalanges  are  often  most  easily 
photographed  with  the  plate  placed  on  the  floor,  the  patient  then  rest- 
ing his  foot  lightly  upon  the  plate ;  the  tube,  of  course,  is  placed  above 
the'  foot  in  such  a  way  that  the  rays  may  fall  upon  it  vertically  ;  in  this 
position  the  tube  is  brought  so  near  the  knee  or  thigh  of  the  patient 
that  the  latter  should  be  screened  from  it  by  a  box  thickly  coated  with 
white  lead  as  already  described. 

^  Me(fical  Press  and  Circular,  London,  March  7,  1900,  p.  240. 
2  British  Medical  Jotirnal,  1899,  II,  Epitome,  p.  85. 


FRACTURES   AND    DISLOCATIONS 


523 


PB^W" 


Fig.  295.  Injury  to  foot.  Injury  occurred  about  a  year  before  the  X-ray  photograph  was  taken. 
Patient,  a  man  about  thirty  years  old.  Testimony  as  to  whether  or  not  there  was  an  injury  of  the  foot 
was  required  in  a  distant  city.     (Compare  with  next  figure.) 


524     THE    ROENTGEN    RAYS   IN    MEDICINE    AND   SURGERY 


Fig.  296.     Uninjured  foot.     (Compare  with  preceding  figure.) 


FRACTURES   AND    DISLOCATIONS 


525 


Advantage  of  comparing  Injured  and  Uninjured  Foot.  —  Cuts  295  and 
296  show  the  advantage  of  takhig  a  photograph  of  both  the  injured  and 
uninjured  foot. 

Fractures  of  Phalanges  of  Great  Toe  and  Fracture  of  First  Phalanx  of 
Second  Toe.  — Alfred  W.,  twenty  years  old,  patient  of  Dr.  H.  VV.  Gush- 
ing, caught  his  right  foot  between  the  elevator  and  the  floor  above,  and 
was  brought  directly  to  the  hospital.     There  was  some  ecchymosis  and 


Fig.  297. 


Fracturo  ot  phai.iiii^es  of  great  toe  and  fracture  of  first  phalanx  of  second  toe. 
these  fractures  were  unsuspected  before  the  radiograph  was  made. 


Two  of 


swelling  across  the  entire  metatarsal  region  and  base  of  toes,  but  no 
fracture  of  metatarsals  was  made  out.  There  was  bony  crepitus  and 
pain  in  phalanx  of  great  toe.  The  X-ray  photograph  showed  fractures 
of  the  phalanges  of  great  toe  and  of  the  phalanx  of  second  toe.  The 
second  fracture  of  the  great  toe  and  the  fracture  of  the  second  toe  were 
not  suspected  by  the  ordinary  methods.  The  uninjured  foot  was  taken 
by  the  side  of  the  injured  foot  and  on  the  same  plate  for  purposes  of 
comparison,  but  is  not  shown. 


526     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

Dislocations 

In  certain  cases  it  is  difficult  to  distinguish  between  a  dislocation 
and  a  fracture ;  radiographs  indicate  clearly  the  conditions  which  are 
present.  The  following  cuts  (Figs.  298,  299,  300,  301,  and  302)  are 
illustrative  of  dislocations. 


Fig.  298.     Dislocation  of  thumb.     Old  injury  to  hand.     Patient  of  Dr.  Blake. 


Fig.  299.     Dislocation  of  both  bones  of  forearm  backward.     Patient  of  Dr.  Edwin  W.  Dwight. 


Fig.  300.  Hugh  C.  Dislocation  and  separation  of  epiphysis  of  lower  end  of  left  femur  in  a  boy 
seven  years  old.  When  the  X-ray  photograph  was  taken  (June  16,  1899),  the  plate  was  put  on  the 
outside  of  the  left  knee. 


F[G.  301.     Hugh  C.     Cut  of  X-ray  photograph  taken  nearly  three  months  later. 
2  M 


CHAPTER    XX 
FOREIGN    BODIES 

It  is  frequently  necessary  or  desirable  to  know  whether  a  foreign 
body  is  present  or  not  in  the  human  body,  and  if  it  is,  to  learn  its  exact 
location  in  order  to  remove  it,  or  to  determine  whether  or  not  its  removal 
should  be  attempted.  The  X-rays  can  show  us  those  substances  whose 
shadows  present  a  contrast  to  the  shadows  of  the  surrounding  tissues, 
and  therefore  objects,  such  as  bullets  or  other  pieces  of  metal  or  glass, 
admit,  as  a  rule,  of  precise  localization,  whereas  a  splinter  of  wood  or 
the  shell  of  a  nut  could  not  be  seen  or  only  under  very  favorable  con- 
ditions. But  in  the  case  of  metallic  objects,  we  have  a  probe  which  is 
exact,  clean,  and  painless.  Moreover,  it  will  determine  the  position 
of  a  bullet,  for  example,  after  the  most  careful  search  by  all  other 
methods  has  failed  to  reveal  its  location. 

Methods  of  Localization. — Various  methods  have  been  devised  for 
the  localization  of  foreign  bodies,  some  of  which  have  already  been 
described  (see  Chapter  III,  page  8i,  and  Chapters  XI  and  XII),  and 
we  will  now  consider  others :  first,  a  method  which  is  carried  out  by 
means  of  the  fluorescent  screen ;  and  second,  those  which  are  carried 
out  by  means  of  X-ray  photographs. 

First  Method ;  by  Fluorescent  Screen.  Part  moved  and  examined 
from  Two  Directions.  —  The  following  description  of  the  manner  in 
which  this  method  is  carried  out  I  quote  from  an  article  which  I 
pubHshed  in  January,  1897:  — 

"  Everything  being  now  in  readiness,  the  fluoroscope  is  placed 
directly  on  the  thigh  (let  us  suppose  the  bullet  is  there),  and  the 
examination  is  begun.  After  looking  a  moment  the  spark-gap  may 
jbe  changed  a  little  in  order  to  increase  or  diminish  the  light,  as  by 
imeans  of  this  variation  more  can  be  seen,  certain  things  showing 
;better  in  a  bright  light  and  others  in  a  less  brilliant  one.  With  a 
ibullet  it  is  generally  well  to  use  a  considerable  amount  of  light.  After 
,the  iluoroscope  has  been  moved  about  a  little,  the  shadow  of  the 
Ibullet  is  found,  and  the  spark-gap  may  again  be  changed,  in  order  to 

531 


532 


THE    ROENTGEN    RAVS    IN    MEDICINE    AND   SURGERY 


get  as  clear  a  shadow  as  possible.  The  physician,  while  still  looking 
through  the  fluoroscope,  then  makes,  with  the  pencil  already  described, 
a  mark  over  the  place  where  the  bullet  seems  to  be,  and  directly  under 
the  fluoroscope ;  he  then  makes  a  corresponding  mark  on  the  side  of 
the  thigh  nearest  the  Crookes  tube,  over  the  shadow  of  the  bullet,  and 
draws  i  and  i  by  the  side  of  each  of  these  two  marks.  Then,  while 
still  looking  through  the  fluoroscope,  the  Crookes  tube  should  be  moved 
horizontally  a  few  inches  to  and  fro  in  order  to  learn  how  deeply  the 
bullet  is  imbedded,  for  if  the  shadow  of  the  bullet  moves  considerably 
in  the  fluoroscope,  the  bullet  is  some  distance  away.  If  it  moves  very 
little,  it  must  be  near  the  fluoroscope  and  the  svu'face  of  the  skin.  If 
far  from  the  surface,  its  shadow  will,  of  course,  be  ill  defined  ;  if  near, 
it  will  be  very  sharply  defined.  Next,  the  patient  should  be  turned  so 
as  to  allow  the  physician  to  look  through  the  thigh  in  a  direction  about 
at  right  angles  to  that  first  taken,  and,  as  before,  a  mark  should  be  made 
with  the  pencil  over  the  place  where  the  bullet  seems  to  be,  both  when 
the  point  of  the  pencil  is  held  directly  under  the  fluoroscope  and  on  the 
side  of  the  thigh  nearest  the  Crookes  tube.  These  points  should  be 
marked  2  and  2,  and  the  bullet  will  be  found  at  the  point  where  the  line 
from  I  to  I  intersects  that  from  2  to  2.  I  have  used  this  method  for 
locating  bullets  in  different  parts  of  the  extremities,  and  in  the  neck, 
thorax,  back,  and  abdomen,  and  usually  the  situation  of  the  bullet  is 
readily  determined  by  this  means.  The  first  bullet  I  located  in  this 
\vay  was  in  April,  1896." 

It  is  well  to  go  over  the  marks  indicating  the  position  of  a  foreign 
body  with  nitrate  of  silver,  so  that  they  will  not  come  off  when  the  part 
is  washed  with  an  antiseptic;  the  stains  caused  by  the  former  may  be, 
removed,  when  desired,  by  painting  them  with  tincture  of  iodine.     The 
iodine  may  in  turn  be  removed  by  dilute  ammonia  water.     Since  nitrate  i 
of  silver  is  a  caustic,  it   should  be  diluted,  as  a  precaution,  with  some] 
less  caustic  substance,  nitrate  of  potash,   for  example.     The  ordinary; 
diluted   lunar   caustic   consists   of   equal   parts  of  nitrate  of  silver  andl 
nitrate  of    potassium.     This  substance  is  too  strong,  and   I  have  had 
a  crayon  made  which  has  a  smaller  proportion  of  nitrate  of  silver,  in 
order  to  obtain  a  pencil  suitable  for  marking  on  the  skin.     The  crayon 
should  be  moistened  when  it  is  to  be  used. 

The  above  method  of  locating  a  foreign  body  applies  to  all  such 
as  can  be  seen  on  the  fluorescent  screen,  but  some  cannot  be  thus 
recognized,  and  in  this  case  the  radiograph   must  be  employed. 


FOREIGN    BODIES 


533 


Second  Method  ;  by  X-Ray  Photograph.    Stereoscopic  Pictures.  —  Dr. 

G.  P.  Girdwood  ^  has  devised  an  excellent  method  of  locating  a  foreign 
body  by  means  of  stereoscopic  radiographs.  Dr.  Mackenzie  Davidson  ^ 
has  also  worked  out  a  similar  method  which  differs  in  certain  particulars 
from  that  of  Dr.  Girdwood. 

Localizers.  —  A  number  of  forms  of  apparatus  have  been  made  for 
the  purpose  of  localization,  among  which  the  following  deserve  special 
mention  :  — 


B( 


''i'liiilii'''iii'M.i'i.M-i.M|       C3      iriTTTTTh 


^ 


X. 


}a 


Fig.  303.  Mackenzie  Davidson  exposer.  The  photographic  plate  is  placed  beneath  the  crossed 
wires  on  the  board.  The  wires  are  inlied  and  leave  marks  on  the  skin  of  the  part,  and  the  image 
of  the  wires  appears  on  the  negative.  This  gives  lines  for  localization.  The  tube  is  suspended  verti- 
cally above  the  transverse  wire  and  equidistant  at  each  exposure  from  a  point  vertically  above  where 
the  wires  cross. 

Fig.  303  and  Fig.  304,  and  descriptions,  are  taken  from  "  The  Use  of  the  Roentgen  Ray  in  the 
War  with  Spain,"  by  Captain  W.  C.  Borden. 


Mackenzie  Davidson  has  devised  a  very  ingenious  apparatus  for 
locating  a  foreign  body.  The  following  account  is  quoted  from  an  arti- 
cle^ by  him  and  Dr.  Hedley  :  — 

"Two  wires  at  right  angles  to  each  other  are  placed  upon  the  photo- 
graphic plate,  film,  or  paper.  The  Crookes  tube  is  then  placed  with 
its  anode  at  a  measured  distance  from  the  plate  and  exactly  perpendicu- 
lar to  where  the  wires  cross.     The  tube  is  fixed  in  a  holder  which  slides 

^  "Stereoskiagraphy,"  Montreal  Medical  Journal,  1899,  P-  193- 
^  British  Medical  Journal,  December  3,  1898,  p.  1669. 

^  "  A  Method  of  Precise  Localization  and  Measurement  by  Means  of  Roentgen  Rays," 
by  J.  M.  Davidson  and  W.  S.  Hedley,  Lancet,  October  16,  1897,  P-  '°°i- 


534     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

in  one  plane.  Further,  one  of  the  cross  wires  must  be  in  exactly  the 
same  plane  as  that  in  which  the  tube  is  to  be  displaced.  The  wires 
being  painted  over  with  some  pigment,  the  part  to  be  photographed  is 
placed  on  the  plate  and  carries  with  it  a  mark  of  the  cross  wires.  The 
tube  is  then  displaced  to  a  measured  distance  to  one  side  of  the  perpen- 
dicular, and  an  exposure  given,  then  to  a  corresponding  point  on  the 
other  side  of  the  perpendicular,  and  another  similar  exposure  given.    The 


Fig.  304.  Mackenzie  Davidson  localizer.  The  negative  is  placed  on  the  glass  plate  in  the  same 
position  relative  to  the  two  points  on  the  crossbar  that  it  occupied  relative  to  the  anode  when  the 
exposure  was  made.  Weighted  threads  are  then  stretched  from  corresponding  points  on  the  image 
to  the  points  on  the  crossbar,  and  their  point  of  crossing  indicates  the  position  which  the  lodged 
missile  occupied  relative  to  the  plate  when  the  exposure  was  made. 

resulting  negative  shows  double  images  from  the  two  different  points  of 
view.  A  further  precaution  is  necessary,  viz.,  to  mark  one  quadrant 
of  the  plate  and  the  corresponding  quadrant  on  the  patient's  skin. 

"  The  negative  having  been  developed,  fixed,  and  slightly  washed,  1 
is  at  once  placed  on  a  horizontal  stage  illuminated  from  below  by  a 
suitable  reflector  (an  arrangement  similar  to  a  retoucher's  desk).     The 
negative  may  be  placed  with  the  gelatin  surface  upward,  or  downward 


FOREIGN    BODIES  535 

if  the  glass  is  not  too  thick.  In  the  case  of  ceHuloid  fihns  it  is  most 
convenient  to  place  them  downward.  The  negative  is  adjusted  so  that 
a  perpendicular  dropped  from  a  notch  in  a  horizontal  scale  falls  upon 
the  point  where  the  shadows  of  the  wires  cross.  On  each  side  of  it 
another  notch  is  made  at  the  exact  distance  and  height  that  the  anode 
of  the  Crookes  tube  occupies  in  the  two  exposures.  A  fine  silk  thread 
is  then  passed  through  each  lateral  notch,  and  a  small  lead  counter- 
weight is  attached  to  one  end  of  each  thread,  while  the  other  is  passed 
through  the  end  of  a  fine  needle.  The  needle  is  weighted  with  lead  so 
that  its  eye  lies  fiat  on  the  surface  of  the  negative.  In  short,  these  two 
silk  threads  represent  the  path  of  the  X-rays,  so  that  if  each  needle  be 
carefully  placed  upon  a  corresponding  point  in  each  shadow,  it  follows 
that  the  point  where  these  threads  cross  marks  the  position  occupied 
by  the  corresponding  part  of  the  actual  object.  Further,  its  distance 
can  be  measured  perpendicularly  from  three  planes  —  from  the  hori- 
zontal which  gives  its  depth,  and  from  the  two  planes  represented  by 
the  shadows  of  the  cross  wires.  By  measuring  any  other  desired  cor- 
responding points  the  precise  size,  position,  and  direction  of  the  object 
can  be  determined,  and  remembering  that  the  cross  wires  have  left  their 
mark  on  the  patient's  skin,  we  can  at  once  from  these  data  give  the 
surgeon  all  the  information  he  can  possibly  desire.  .  .  .  Dr.  Hedley 
suggested  that  instead  of  displacing  the  tube,  two  tubes  be  used  and  a 
simultaneous  exposure  given." 

Harrison's  Apparatus.  —  Harrison,^  following  the  idea  described  by 
Davidson  in  the  British  Medical  J om-nal,  January  i.  1898,  has  devised 
a  localizer  which  he  considers  rather  simpler.  His  description  is  as 
follows  :  — 

"The  stand  of  mv  focus  tube  is  7  inches  wide  and  about  18 
inches  long,  and  I  fix  the  tube  so  that  its  centre  is  7  inches  above  the 
board.  The  tube  can  be  moved  to  either  side,  and  a  point  is  marked 
on  the  extreme  edge  of  the  board  on  each  side,  directly  under  its  centre. 
These  points  are  joined  by  a  straight  line,  and  a  line  is  drawn  at  right 
angles  through  the  centre  of  the  first  line.  The  sensitive  plate  should 
be  so  placed  that  its  centre  coincides  with  this  point.  A  photograph 
is  taken  with  the  tube  over  each  of  the  lateral  points  in  succession  on 
the  same  plate,  and  the  distances  of  the  images  of  the  foreign  body  from 
the  sides  of  the  board  must  be  accurately  measured. 

"  I  now  draw  on  a  board  a  square  of  7  inches  and  divide  one  side 

1  British  Medical  Journal,  February  12,  1898. 


536     THE    R0P:NTGEN    rays    liN    MEDICINE    AND   SURGERY 

into  a  scale.  On  this  scale  I  mark  the  distances  of  the  images  of  the 
object  from  the  sides  of  the  board,  with  two  pins.  I  also  fasten  two 
pins  at  the  two  opposite  corners  of  the  board.  Two  threads  are  now 
fastened  to  these  pins  and  passed  round  the  pins  on  the  scale.  Their 
point  of  intersection  will  show  the  position  of  the  object." 

Harrison  has  made  a  modification  of  his  apparatus  so  that  the  whole 
object,  or  as  many  points  as  are  desired,  can  be  localized,  and  if  the 
subject  examined  is  bigger  than  the  hand,  a  larger  square  than  the  one 
described  can  be  made.  His  description  of  this  modified  apparatus^  is 
as  follows :  — 

"  A  7-inch  square  is  drawn  on  a  board,  and  its  centre  accurately 
marked  ;  at  the  ends  of  a  line  drawn  through  the  centre,  perpendicular 
to  two  of  the  sides,  two  upright  rods  are  fixed  (for  convenience  of  car- 
riage these  can  be  made  to  take  in  and  out);  at  a  height  of  7  inches  on 
each  of  these  pillars  a  hook  or  loop  is  placed. 

"  Take  the  case  of  a  needle  in  the  hand.  A  double  photograph  of 
the  hand  and  needle  is  taken  with  the  light  alternately  right  and  left. 
A  tracing  of  this  photograph  is  then  taken  on  the  sensitive  side,  mark- 
ing distinctly  the  ends  of  the  needle.  This  tracing  is  then  placed  so 
that  its  centre  coincides  with  the  centre  of  the  square ;  pins  are  then 
stuck  slantingly  through  the  tracing  into  the  board  at  the  ends  of  the 
needle.  Cross  threads  are  carried  from  the  pins  to  the  loops,  and  kept 
stretched  by  small  weights.  Where  these  threads  intersect  will  show 
the  position  of  the  needle  relatively  to  the  sensitive  plate  which  is  repre- 
sented by  the  tracing." 

Grossman's  Method  for  localizing  a  Foreign  Body  in  the  Eye.  — 
Karl  Grossman,^  in  localizing  a  foreign  body  in  the  eye,  utilizes  the  eye 
itself  for  the  purpose  of  obtaining  the  necessary  parallax  of  the  shadow  ; 
the  vacuum  tube,  the  head  of  the  patient,  and  the  photographic  plate 
retain  their  relative  position  to  each  other  unchanged.  Grossman  de- 
scribes his  method  as  follows  :  — 

"  Either  one  or  two  pairs  of  skiagrams  are  taken.  The  first  pair  is 
obtained  by  making  the  patient  look  (a)  downward,  (d)  upward,  in 
the  same  plane,  the  X-rays  coming  from  the  other  side  of  the  face  and 
somewhat  in  front  of  the  face.  If  the  foreign  body  be  in  the  eyeball, 
the  shadow  has  moved  from  (a)  to  (/?)  as  follows  :  — 

1  Bri^is^  Medical  Journal,  April  2,  1898,  pp.  882-883. 

-  "  Localization  of  Foreign  Bodies  in  the  Eye  by  X-Rays,"  Lherpool  Medico-Chir.  Journal, 
January,  1899,  pp.  359-361. 


FOREIGN    BODIES 


537 


Upward,  if  in  the  anterior  half  hemisphere 

Downward,  "  "     "   posterior   " 

Forward,  "  "     "     inferior     " 

Backward,  "   "     "    superior    "  " 

the  axis  of  these  four  half-hemispheres  being  at  the  same  time  the  axis 
of  rotation  for  the  upward  movement. 

"  If  the  shadow  has  not  moved,  the  foreign  body  might  still  be  in  the 
eyeball,  viz.  at  any  point  on  the  axis  of  rotation.  In  this  case  the  sec- 
ond pair  of  skiagrams  would  become  necessary,  the  patient,  this  time, 
having  to  look  at  a  point  (r)  temporalward,  {d)  nasalward,  in  the  hori- 
zontal plane.  A  movement  of  the  shadow  from  {c)  to  {d)  would  mean 
the  presence  of  a  foreign  body  in  the  eye,  viz.  in  the  temporal  hemi- 
sphere if  forward  ;  in  the  nasal  hemisphere  if  backward. 

"  It  may  be  mentioned  that  the  relative  position  of  the  tube,  head,  and 
plate  need  only  remain  the  same  for  the  two  exposures  of  each  pair ; 
viz.  for  {a)  and  (/;)  on  the  one  hand,  and  for  (c)  and  {d)  on  the  other, 
but  may  be  a  different  one  for  each  pair  of  skiagrams. 

"  In  order  to  give  landmarks  of  orientation  to  the  skiagrams,  thin  lead 
wire  or  narrow  strips  of  lead  foil  were  applied  in  various  ways ;  if  neces- 
sary, they  can  be  placed  in  the  conjunctival  sac." 

Dr.  Sweet's^  Apparatus. — The  apparatus  is  fixed  to  the  patient's 
head,  and  by  knowing  the  distance  of  one  of  the  balls  of  the  indicator 
from  the  centre  of  the  cornea  and  the  distance  between  the  two  balls 
the  position  of  the  metal  in  the  eye  may  be  determined. 

Dr.  Sweet  ^  has  employed  the  rays  for  diagnostic  purposes  in  thirty- 
five  cases  of  injury  to  the  eyes.  In  thirteen  cases  there  was  shown  to 
be  no  foreign  body  in  or  near  the  eye.  In  the  remaining  twenty-two  a 
foreign  body  was  found  either  in  the  eyeball  or  the  orbit,  the  localiza- 
tion being  verified  in  sixteen  cases  by  magnetic  extraction,  or  by  enuclea- 
tion, and  in  two  cases  by  the  ophthalmoscope.  Three  cases  were  gunshot 
injuries  and  no  operation  was  performed  for  the  removal  of  the  shot ; 
while  one  patient  did  not  reappear  after  the  radiographs  were  made. 

Dr.  Sweet  considers  that  these  cases  show  an  accuracy  in  the  deter- 
mination of  the  situation  of  foreign  bodies  in  the  eye  by  the  use  of  the 
Roentgen  rays,  that  he  believes  is  not  equalled  by  any  other  means.     If 

1  "The  Value  and  Method  of  determining  the  Precise  Location  of  Pieces  of  Metal  in  the  Eye 
by  Means  of  the  Roentgen  Rays,"  Archives  Ophth.,  New  York,  November  27,  1898,  pp.  377-399- 

-  "  Locating  Foreign  Bodies  in  the  Eye  ;  Results  of  Two  Years'  Work  with  the  Roentgen 
Rays,"  Philadelphia  Afedical  Journal,  October  14,  1899,  pp.  718-719. 


538     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

the  examination  is  negative,  both  the  surgeon  and  the  patient  are  reas- 
sured. If  the  radiograph  indicates  that  a  foreign  body  is  in  the  eye,  an 
attempt  to  remove  it  may  be  made  before  a  firm  exudate  has  formed 
about  it.  To  wait  until  the  inflammation  has  subsided,  in  the  hope  of 
determining  the  situation  of  the  metal  by  the  ophthalmoscope,  consumes 
valuable  time  and  menaces  the  safety  not  only  of  the  injured  but  of  the 
sound  eye. 

Piece  of  Copper  in  the  Eye.  —  One  of  the  first  cases,  so  far  as  I  am 
aware,  in  which  the  X-rays  helped  to  indicate  the  presence  of  a  foreign 
body  in  the  eye,  was  that  of  a  patient  who  was  brought  to  me  in  June, 
1896,  by  my  brother.  Dr.  Charles  H.  Williams.  Messrs.  Charles  L. 
Norton,  R.  R.  Lawrence,  and  myself  examined  this  patient  in  the 
Rogers  Laboratory  of  Physics  of  the  Massachusetts  Institute  of  Tech- 
nology. 

The  patient,  M.  M.,  seventeen  years  old,  was  brought  by  Doctor 
Shurtliff  of  Somerset  to  Doctor  Williams  on  June  5,  1896.  His  descrip- 
tion of  the  case  is  as  follows  :  ^  — 

"  The  day  before  he  had  placed  a  Flobert  rifle  cartridge  in  a  vise 
and  hammered  it ;  the  cartridge  exploded,  and  a  piece  struck  his  left 
eye.  Examination  showed  no  injury  to  the  eyeHds,  but  a  vertical  cut 
extended  two-thirds  across  the  cornea,  the  anterior  chamber  was  empty, 
and  the  pupil  was  filled  with  a  mass  of  opaque  lens  substance.  Under 
atropine  there  was  some  adhesion  between  the  iris  and  lens  capsule,  and 
no  view  could  be  had  of  the  interior  of  the  eye  on  account  of  the  opac- 
ity of  the  lens.  There  was  very  little  redness  of  the  sclera,  and  no 
complaint  of  pain.  Light  projection  was  fairly  good  upward,  inward, 
and  outward,  but  uncertain  downward ;  fingers  could  not  be  counted. 

"  It  was  hard  to  decide  whether  this  injury  was  caused  by  a  piece  of 
cartridge  which  had  struck  the  eye  and  then  rebounded,  or  whether  the 
metal  had  lodged  within  the  eye.  No  use  could  be  made  of  the  elec- 
tromagnet for  diagnosis  and  removal,  as  the  metal  was  probably 
copper.  ..." 

The  patient  was  laid  on  the  table  with  his  injured  eye  close  to  the 
plate  holder,  and  the  vacuum  tube  so  placed  that  the  rays  passed 
partly  across  the  bridge  of  the  nose,  and  partly  through  the  thin  nasal 
and  orbital  bones  to  the  injured  eye,  and  so  on  to  the  plate.     After  ten 

1  "  A  Case  of  Extraction  of  a  Bit  of  Copper  from  the  Vitreous,  where  X-Rays  helped  to  locate 
the   Metal,"  by  Dr.  Charles  H.  Williams.     Boston  Medical  and  Surgical  Journal,  August  13, 


FOREIGN    BODIES  539 

minutes'  exposure  the  developed  plate  showed  what  appeared  to  be  a  for- 
eign body  a  little  back  of  the  centre  of  the  eyeball.  A  second  X-ray 
photograph  with  the  tube  in  a  different  position  showed  no  foreign  body. 
It  may  be  that  this  exposure  was  not  suitable,  or  that  the  thin  metal 
strip,  which  was  found  later  was  turned  edgewise  to  the  light,  thus  giv- 
ing a  less  marked  impression  on  the  plate. 

Dr.  Charles  H.  Williams  operated  and  removed  a  thin,  nearly  straight 
piece  of  copper,  6  millimetres  long  by  3  millimetres  wide,  and  of  the 
thickness  of  the  cartridge  shell. 

Bullet  in  Head.  — An  interesting  case  of  the  localization  of  a  bullet 
by  the  X-rays  is  given  by  R.  C.  Lucas. ^  The  patient  was  a  child  ten 
years  old,  who  was  shot  in  the  back  of  the  head.  There  was  a  circular 
wound  over  the  upper  part  of  the  occipital  bone,  about  6  millimetres 
in  diameter,  rather  to  the  right  of  the  median  line.  A  radiograph 
showed  that  the  bullet  had  separated  into  two  pieces,  one  of  which  was 
lying  near  the  hole  in  the  skull,  and  the  other  about  4-5  centimetres  far- 
ther on.  After  the  foreign  bodies  were  removed  the  improvement  was 
marked. 

Bullet  in  Head.  —  K.  W.,  30  years  old,  entered  the  surgical  side  of 
the  Boston  City  Hospital  November  23,  1899.  Service  of  Dr.  Munro. 
Four  years  ago  the  patient  was  shot  through  the  right  side  of  the  face, 
but  did  not  suffer  much  from  the  injury  until  three  weeks  ago.  At 
times  since  then  her  jaws  have  seemed  to  set  tightly,  and  there  was  swell- 
ing on  the  right  side  of  the  face,  accompanied  with  much  pain.  About 
1.25  centimetres  anterior  to  the  lobe  of  the  ear  on  this  side  was  a  small 
scar.  There  was  a  slight  tenderness  about  this  region  on  pressure,  also 
over  right  temporal  region.  On  November  28,  with  the  aid  of  two 
X-ray  photographs.  Dr.  Munro  removed  the  bullet,  which  was  found 
2.5  centimetres  from  the  surface,  imbedded  in  fat  tissue  close  to  the 
temporal  bone.     The  patient  was  discharged  well. 

Foreign  Body  in  (Esophagus.  —  The  following  cut  shows  the  condi- 
tion of  a  girl  13  years  old,  who  was  brought  to  me  for  an  X-ray  exami- 
nation. On  December  26,  1898,  she  had  swallowed  a  fifty-cent  piece; 
subsequent  to  this  vomiting  occurred  if  anything  stuck  in  her  throat  when 
eating.  Liquids  were  swallowed  without  difficulty.  I  examined  her 
with  the  fluorescent  screen,  and  located  the  position  of  the  coin  as  fol- 
lows :  opposite  second  rib  in  front  and  fourth  dorsal  vertebra  behind  ; 
in  front,  from  6  to  12.5   millimetres  to  right  of  median  line;  behind,  a 

1"  Localization  of  Bullets  by  X-Rays,"  British  Medical  Journal,  October  21,  1899,  p.  1064. 


540     THK    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

little  to  right  of  median  line.     A  radiograph,  from  which  this  cut  was 
made,  was  also  taken.     (See  Fig.  305.) 

Dr.  J.  F.  Baldwin  ^  describes  the  case  of  a  child  who  without  any- 
assignable  cause  had  symptoms  of  croup  with  inability  to  swallow. 
About  a  month  later  the  child  was  very  much  emaciated.  Dr.  Baldwin 
advised  an  X-ray  examination,  which  showed  a  button  in  the  oesopha- 
gus, about  five  centimetres  above  the  stomach. 


Fig.  305.     Half  dollar  in  oesophagus. 

Piece  of  Steel  in  Arm  found  only  by  X-Rays.  —  A  piece  of  steel 
entered  the  right  arm  of  a  man  twenty  years  old.  An  unsuccessful 
attempt  was  made  to  find  the  steel ;  the  arm  became  much  swollen  and 
the  patient  came  to  the  out-patient  department  of  the  Boston  City  Hos- 
pital in  September,  1899,  where  another  unsuccessful  attempt  was  made 
under  cocaine  to  find  the  foreign  body.  Two  X-ray  photographs  were 
then  taken  (see  Figs.  307,  308)  and  the  steel  was  removed  under  ether. 

^  Columbus  Medical  Journal,  February,  1900,  p.  73. 


542 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


This  case  illustrates  the  advantage  of  taking  two  photographs,  each 
from  a  different  point  of  view,  as  two  views  give  the  surgeon  more  exact 
knowledge  of  the  position  of  the  object  than  one  alone  could  do,  and 


Fig.  307.     Piece  of  steel  in  arm.     Found  only  after  radiographs  were  made.     Antero-posterior  view. 


thus  assist  him  in  operating  Likewise  this  case  shows  the  usefulness 
of  X-ray  examinations  in  locating  foreign  bodies,  for  it  will  be  noticed 
that  two  examinations  without  the  use  of  the  X-rays  failed  to  find  this 


FOREIGN    BODIES  543 

foreign  body,  although  it  was  of  considerable  size  and  in  a  part  easy  of 
access. 

Importance  of  Two  Views ;  Needle  in  Os  Calcis.  —  This  case  is  instruc- 
tive because  it  shows  the  need  in  most  cases  of  two  X-ray  photographs, 


Fig.  308.    Piece  of  steel  in  right  arm.     Lateral  view.     (See  also  Fig.  307.) 

each  taken  from  a  different  point  of  view.  One  only  was  made  of  this 
case  at  first  (see  Fig.  309),  and  the  needle  was  then  sought  for  carefully 
under  ether  for  more  than  an  hour  without  success.  The  second  X-ray 
picture  was  made  from  an  antero-posterior  direction  and  showed  that 
the  piece  of  needle  was  in  the  middle  of  the  os  calcis.    If  the  precaution 


544     THE    ROENTGExN    RAVS   IN    MEDICINE    AND    SURGERY 

had  been  taken  to  make  either  a  stereoscopic  picture  or  two  views,  one 
from  a  lateral  and  the  other  from  an  antero-posterior  point  of  view,  the 
first  Ions:  search  would  have  been  avoided. 


Fig.  309.     Needle  in  middle  of  os  calcis. 


forp:ign  bodies 


545 


Precautions  to  be  taken  in  Regard  to  Needles.  —  A  needle  should  be 
cut  out  directly  after  it  has  been  located  by  the  X-ray  examination,  for 


Fig.  310.     Needle  in  hand.     The  eye  of  the  needle  can  be  seen.    Patient  of  Dr.  J.  B.  Blake. 


if  there  is  delay  it  may  change  its  position.  For  example,  a  young  woman 
was  examined  at  the  hospital  with  the  fluorescent  screen,  and  a  needle 
found  in  her  right  hand  between  the  carpal  ends  of  the  second  and  third" 


546     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

metacarpal  bones.  The  next  day  two  negatives  showed  that  the  needle 
had  moved  to  a  point  over  the  wrist.  About  two  weeks  later  it  was 
found  between  the  first  and  second  metacarpal  bones,  about  opposite 


( 


Fig.  311.     Needle  in  hand  ;  antero-posterior  view.     (See  following  figure.)     The  tube  was 
70  centimetres  distant  and  directly  opposite  the  metal  washer. 


the  middle  of  the  first  metacarpal.     Twenty-four  hours  later  an  opera- 
tion was  performed,  but  the  needle  was  not  found. 

Forster  and  Hugi  ^  give  a  detailed  account  of  experiments  made  to 


1  Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  B.  I,  pp.  1 70-179. 


o 


Fig.  312.     Needle  in  hanrl ;    lateral  view.      Oee  pi eeeding  figure.) 


548     THE    ROENl'GEiN    RAVS    IN    MEDICINE   AND   SURGERY 


I-ii;.  313.     Xc-edle  in  wrist;   ankio-pu^terior  view.     (See  also  following  figure.) 


Fig.  314.     Needle  in  wrist ;  lateral  view .     t  rum  same  patient  as  shown  in  precetimg  ngure. 


550     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

determine  how  small  a  piece  of  metal  could  be  seen  in  a  radiograph. 
They  used  four  fragments  of  needles  of  known  weight  and  size,  and 
attached  them  firmly  to  various  parts  of  the  human  body,  and  then 
radiographed  them.     The  summary  of  their  experiments  is  as  follows: 

1.  An  iron  foreign  body  in  the  hand  ;  weight  i  niilligramme.     The  exposure  was  ten  sec- 

onds, and  the  tube  was  at  a  distance  of  20  centimetres  from  the  photographic  plate. 

2.  Iron  foreign  body  in  the  forearm  :   weight  i  milHgramme.    Exposure  thirty  seconds; 

distance  of  tube  30  centimetres. 


Fig.  315.     This  cut  shows  a  piece  of  glass  in  the  upper  finger.     Patient  of  Dr.  Lund. 

3.  Iron  foreign  body  in  the  upper  arm  ;  weight  i  milHgramme.    Exposure  thirty  sec- 

onds ;  distance  of  tube  30  centimetres. 

4.  Iron  foreign  body  in  the  foot ;  same  weight  as  above.     Exposure  one  to  two  min- 

utes :  distance  of  tube  as  above. 

5.  Iron  foreign  bodv  in  the  knee;  weight  4  milligrammes.     E.xposure   five  minutes; 

distance  of  tube  40  centimetres. 

6.  Iron  foreign  body  in  the  thigh  ;  weight  i  milligramme.    Exposure  five  minutes  ;  dis- 

tance of  tube  40  centimetres ;  but  it  could  be  seen  only  when  the  image  of  the 
needle  fell  on  the  muscle  and  was  not  in  the  shadow  of  the  femur. 

7.  Iron  foreign  body  in  the  shoulder ;  weight  i  milligramme.     Exposure  five  minutes ; 

distance  of  tube  40  centimetres. 

8.  Iron  foreign  body  in  the  thorax  of  children  four  to  twelve  years  old  ;  weight  i  milli- 

gramme.   Exposure  five  minutes  ;  distance  of  tube  40  centimetres,  unless  the  body 
was  hidden  by  the  sternum  or  backbone. 

9.  Iron  foreign  body  in  the  abdomen  of  children  four  to  twelve  years  old ;  weight  4 

milligrammes.     Exposure  ten  minutes;  distance  of  tube  40  centimetres. 


FOREIGN    BODIES 


551 


CHAPTER   XXI 

X-RAVS    IN    MILITARY    SURGERY 

It  may  be  said  that  the  principles  which  govern  the  use  of  the 
X-rays  in  this  field  are  the  same  as  those  which  obtain  under  the 
conditions  in  which  an  apparatus  that  has  its  independent  source  of 
electricity  is  used  ;  therefore  only  a  few  words  are  necessary  on  this 
subject. 

The  X-rays  have  been  employed  in  military  surgery  with  success. 
It  has  been  well  said  by  Dr.  Haughton  that  "  The  X-rays  have  furnished 
the  army  surgeon  with  a  probe  which  is  painless  ;  which  is  exact ;  and, 
most  important  of  all,  which  is  aseptic." 

Dr.  Abbott  and  Mr.  Symons  ^  believe  that  the  X-rays  will  be  of  great 
use  in  future  wars,  but  not  at  the  actual  front.  They  found  that  a 
screen  saved  much  time  because  the  question  of  depth  was  so  easily 
approximately  solved  by  its  aid.  The  X-rays  not  only  assisted  them  to 
localize  bullets,  but  also  indicated  other  sources  of  irritation,  namely, 
pieces  of  dirt  and  sequestra,  and  thus  proved  useful  guides  to  a 
secondary  operation. 

Surgeon  Major  Beevor,^  M.  B.,  Army  Medical  Staff,  on  the  contrary, 
considers  that  every  civilized  nation  should  have  an  X-ray  apparatus  not 
only  at  base  hospitals,  but  wherever  soldiers  are  fighting.  The  apparatus 
used  during  operations  on  the  frontier  of  India  was  a  ten-inch  spark 
coil  with  a  primary  battery.  If  the  roads  are  not  good,  he  thinks  that 
a  portable  apparatus  should  not  weigh  more  than  eighty  to  one  hundred 
pounds,  so  that  it  can  be  slung  from  a  pole  and  be  carried  by  two  men. 
One  difficulty  encountered  with  the  apparatus  was  the  melting  of  the 
wax,  by  the  hot  sun,  that  insulated  the  wire  of  the  secondary  coil,  but 
this  trouble  was  overcome  by  the  use  of  a  mixture  of  paraffin  wax  and 

^  "Surgery  in  the  Gmeco-Turkish  War,"  Lancet,  London,  January  14,  1899,  p.  So. 
^Report  of  Address  made  before  the   Royal   United  Service   Institution,  British  Medical 
Journal,  May  28,  1898,  p.  1408. 

553 


554     'i^HE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

resin  which  did  not  melt  under  150°  F.  A  covering  of  felt  protected 
the  coil  from  the  sun,  rain,  snow,  and  frost. 

Major  Battersby  ^  states  that  the  ordinary  methods  were  insufificient 
to  demonstrate  the  position  of  the  bullet  in  the  tissues,  or  to  show  that  a 
bullet  was  not  present,  in  twenty-one  men  out  of  one  hundred  and  twenty 
.who  were  wounded  at  the  battle  of  Omdurman  and  carried  into  the 
hospital.  In  twenty  of  these  cases  the  diagnosis  was  reached  by  means 
of  the  X-rays  ;  in  the  twenty-first  case  the  patient  was  too  feeble  to  bear 
the  examination. 

Major  Battersby  found  that  the  fluorescent  screen  was  advantageous 
in  that  any  part  of  the  body  could  be  examined  without  delay,  but  it  was 
most  useful  at  night,  because  no  dark  room  was  available  and  the  hood 
employed  was  not  sufficient  to  keep  out  the  intense  sunlight.  He  like- 
wise found  that  when  plates  are  used  in  warm  countries  an  alum  bath 
is  necessary  because  the  water  w-hich  is  used  in  the  developing  solution 
and  to  wash  the  plate  is  always  warm.  He  used  a  bicycle  to  charge  the 
storage  battery  ;  but  thought  in  the  Soudan  a  static  machine  was  the 
ideal  apparatus. 

Edward  Loison  ^  suggests  the  use  of  Eastman  paper  of  bromide  of 
silver,  or  films,  in  military  surgery  for  taking  X-ray  photographs,  in  order 
to  avoid  the  risk  run  of  breaking  the  plates,  if  these  are  used.  Glass 
plates,  too,  are  heavy  to  carry  ;  still,  he  thinks  them  the  best. 

Captain  W.  C.  Borden,^  Assistant  Surgeon  in  the  United  States 
army,  expresses  the  following  opinion  in  regard  to  the  need  of  an 
X-ray  apparatus  in  military  surgery,  and  the  place  where  it  should 
be  kept : — 

"  The  use  of  the  Roentgen  ray  has  marked  a  distinct  advance  in 
military  surgery. 

"  It  has  favored  conservatism  and  promoted  the  aseptic  healing  of 
bullet  wounds  made  by  lodged  missiles,  in  that  it  has  done  away  with 
the  necessity  for  the  exploration  of  wounds  by  probes  or  other  means, 
and  by  this  has  obviated  the  dangers  of  infection  and  additional  trau- 
matism in  this  class  of  injuries. 

"  In  gunshot  fractures  it  has  been  of  great  scientific  value  by  show- 
ing the  character  of   the  bone  lesions,  the  form  of  fracture,  and  the 

^  British  Medical  Journal,  January  14,  1899,  p.  112. 

2  Arch,  de  Med.  et  Pharm.  Mi  lit.,  Paris,  1899,  Vol.  33,  p.  435. 

3  "  The  Use  of  the  Roentgen  Ray  by  the  Medical  Department  of  the  United  States 
Army  in  the  War  with  Spain." 


X-RAYS    IN    MILITARY   SURGERY 


555 


amount  of  bone  comminution  produced  by  the  small  caliber  and  other 
bullets  —  conditions  which  could  not  have  been  otherwise  determined  in 
the  living  body. 

"  In  the  treatment  of  these  traumatisms  it  has  been  of  great  value 
in  determining  the  course  of  treatment  to  be  pursued,  as  its  use,  together 
with  the  course  of  the  cases  under  treatment,  has  shown  that  aseptic  or 
septic  condition  of  the  wound  is  of  far  greater  importance  than  the 
amount  of  bone  comminution.  This  is  illustrated  by  those  cases  of 
extensive  bone  comminution  which,  when  connected  with  aseptic  wounds, 
progress  to  favorable  termination  with  a  minimum  of  immediate  and 
remote  ill  effects  ;  while  those  cases  in  which  the  bone  traumatism  is 
slight,  if  compHcated  by  infection  of  the  wound,  are  much  more  difficult 
to  treat  and  serious  in  their  result.   .   .   . 

"  The  many  cases  of  lodged  bullets  in  which  the  bullets  were  left 
undisturbed  until  the  patients  reached  a  general  hospital  or  hospital 
ship,  where  the  missiles  were  located  by  the  Roentgen  ray  and  removed 
under  aseptic  technic  with  complete  safety  to  the  patient  and  rapid 
recovery,  prove  the  non-necessity  for  the  use  of  Roentgen  ray  apparatus 
in  field  or  other  advanced  hospitals.  Even  where  the  bullet  can  be 
readily  located  without  the  use  of  the  Roentgen  ray,  the  experience  of 
the  late  war  and  the  opinion  of  numerous  authorities  lead  to  the  conclu- 
sion that  the  zeal  of  the  surgeon  should  not  cause  him  to  remove  the 
missile  at  the  field  hospital  except  in  special  cases.  Infection  is  almost 
sure  to  occur  from  the  almost  absolute  impossibility  of  obtaining 
asepsis  under  conditions  which  are  present  at  the  front,  and  the  recovery 
of  the  patient  is  delayed  and  the  functions  of  the  wounded  part  likely 
to  be  impaired  in  consequence  of  the  suppuration  which  will  follow." 


CHAPTER    XXII 


DISEASES    OF    THE    BOXES    AND    OF    THE   JOINTS 


BONES,   i 


The  change  in  chemical  composition  accompanying  pathological 
processes  is  obvious  in  certain  diseases  of  the  bones  and  of  the  joints  by 
the  aid  of  the  fluorescent  screen,  but  far  more  so  by  that  of  X-ray  photo- 
graphs, and  a  careful  study  of  good  radiographs  will  do  much  to  make 
our  conception  of  these  diseases  clearer.  More  exact  diagnosis  can  be 
made  in  some  cases  by  means  of  the  X-rays,  and  in  other  cases  a  definite 
diagnosis  cannot  be  made  without  them. 

The  following  table  will  serve  to  place  before  the  eye  of  the  reader 
some  of  the  conditions  in  which  X-ray  examinations  are  of  service :  — 

r  Periostitis. 
Osteitis.     Spina  ventosa. 

Osteitis  Deformans.     (Affects  both  bone  and  periosteum.) 
Osteomyelitis.     Abscess,  Necrosis,  Sequestra. 
Regeneration  of  Bone  after  Operation.     Callous  Formation. 
Tuberculosis.     (Nearly  always  begins  in  epiphyses  ;  sometimes  in  joints.) 
Syphilis. 

Rickets.     Coxa  vara. 
Acromegalia. 
L  Chronic  Pulmonary  Osteoarthropathy. 
Osteoma.     (Exostoses.) 
Chondroma. 
Osteochondroma. 
Osteosarcoma. 
Differentiation  of  bony  |  Chondrosarcoma. 
from  other  tumors.      ^Cancer.     (Rare.) 
Tuberculosis. 
Coxitis. 
Syphilis. 

Rheumatoid  arthritis.     (Atrophy  of  bone  and 
all  joint  structures.) 
JOINTS.  ^  Arthritis  Deformans.  J  Osteo-arthritis.      (Hypertrophy  of   bone  and 

cartilages.) 
Charcots. 
Rheumatism,  acute. 

Deposits  about  Joints,  including  urate  of  soda  or  lime  salts. 
^  Loose  Cartilage. 

556 


NEW   GROWTHS. 


r 


-M 


Fig.  318.     Acute  periostitis  of  the  radius. 


Fig.  319.     Augusta  G.,  loriy-hvc  years  olti.     Chronic  periostitis  of  the  fibula  and  of  a  small  portioi^ 

of  the  tibia. 


DISEASES   Of   THE    BONES   AND   OF   THE   JOINTS  559 

Diseases  of  the  Bones 

Methods  of  Examination. — The  general  directions  already  given  for 
examination  of  the  bones  when  fractured  largely  apply  in  the  following 
diseases.  It  is  well  to  place  the  healthy  and  diseased  bone  on  the  same 
plate  and  photograph  them  thus,  for  purposes  of  comparison.  The  best 
results  can  be  obtained  if  a  new  tube  that  has  a  low  resistance  is  used. 


Fii^.  320.    Augusta  G.,  forty-five  years  of  age.     From  same  patient  as  Fig.  319.     Shuw.- 

substance  in  plialanges. 

The  special  difficulties  lie  in  so  arranging  the  apparatus  as  to  obtain  the 
best  differentiation,  and  in  the  correct  reading  of  the  radiograph,  par- 
ticularly in  cases  where  the  disease  is  beginning  and  only  a  small  focus 
is  affected.  The  changes  in  the  outline  and  thickness  of  the  bones,  of 
the  periosteum,  in  the  cancellated  structure  of  the  bones,  in  the  amount 
of  rays  absorbed  by  the  tissues,  should  all  be  carefully  studied  in  the 
radiographs.  A  well-made  radiograph  may  be  defined  as  one  which 
shows  the  details  of  the  bones,  and  also  of  the  soft  parts,  such  as  skin, 


560     THE   ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 


Fig.  321.     Osteitis  of  tibia  and  fibula.     Fracture  of  fibula. 


DISEASES   OF   THE    BONES   AND    OF   THE   JOINTS  56 1 

fatty  tissues,  muscles,  tendons,  and  in  some  cases  normal  arteries,  with 
surprising  clearness.  I  regret  that  the  beautiful  detail  shown  by 
them  cannot  always  be  reproduced  by  any  method  that  it  is  practicable 


Fig.  322.    Z.     Osteomyelitis,  with  necrosis  of  lower  jaw.     Patient  of  Dr.  E.  H.  Nichols,  out-patient 
department,  Boston  City  Hospital. 


562     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

to  use  in  a  book ;  but  the  half-tones  given  here  indicate  in  part  what 
the  negatives  show. 

Spina  Ventosa.  —  Feilchenfeld  ^  reports  on  a  typical  case  of  spina- 
ventosa  of  the  right  forefinger  in  a  boy  eight  years  of  age.  The  X-ray 
photograph  showed  the  swelling  of  the  soft  parts,  a  very  slight  thicken- 
ing of  the  bone,  and  two  quite  small  carious  foci  at  the  base  of  the  pha- 
lanx. The  writer  notes  the  importance  of  this  case  because  it  shows 
the  possibility  of  early  diagnosis  at  a  time  when  a  small  diseased  place 
in  the  bone  could  not  otherwise  be  located. 

Regeneration  of  the  Bones  after  Operation.  —  The  following  cases  are 
illustrative :  — 

Oilier^  describes  the  case  of  a  girl  fifteen  years  old  who  had  suffered 
from  suppurative  osteomyelitis  of  the  tibia,  with  invasion  of  the  articula- 
tions of  the  astragalus  and  persistent  suppuration  of  tarsus.  In  October, 
1889,  he  removed  a  piece  of  the  tibia  28  centimetres  long,  which  included 
the  whole  of  the  epiphysis  with  its  malleolus,  and  he  also  completely 
removed  the  astragalus.  The  fibula,  although  attacked  by  osteitis,  was 
simply  abraded,  but  as  it  was  longer  than  the  tibia  and  made  the  foot 
turn  inward,  Oilier  cut  out  the  external  malleolus.  May  i,  1897,  a 
radiograph  was  taken  which  showed  that  the  new  tibia  was  almost  as 
long  as,  and  thicker  than,  the  normal  one  in  a  large  part  of  its  extent; 
its  exterior  surface  was  slightly  irregular  ;  the  darkness  of  the  shadow 
indicated  compact  tissue ;  its  malleolus  was  very  clearly  marked.  The 
astragalus  was  indicated  in  the  radiograph  by  an  osseous  mass  insig- 
nificant in  size.  The  patient  can  dance  without  fatigue  and  walk  a  dis- 
tance of  from  10  to  12  kilometres. 

Oilier  reports  a  second  case  of  a  patient  sixteen  years  old  on  whom 
he  had  operated  five  years  before.     The  radiograph  showed  that  new! 
bone  had  formed.  ; 

Dr.  H.  W.  Gushing^  gives  radiographs  and  an  instructive  account] 
of  a  case  of  acute  osteomyelitis  in  a  boy  sixteen  years  of  age  upon  \ 
whom  he  operated  successfully.  Two  years  after  the  removal  of  the/ 
left  tibia  the  patient  was  well  and  strong,  and  walked  unaided  and  with-ij 

1  Berlin  klin.  Wochenschr .,  May,  1896,  p.  403.  j 

2  "Demonstration  par  les  rayons  de  Roentgen  de  la  regeneration  osseuse  chez  Fhomme  a  ^ 
la  suite  des  operations  chirurgicales,"  Compt.  rend.  Acad.  d.  Sc,  Paris,  1897,  CXXIV,  pp.  | 
1070-1074. 

3  "A  Method  of  Treatment  for  the  Restoration  of  Entire  TibiK  Necrotic  from  Acuteij 
Osteomyelitis,"  Annals  of  Surgery,  August,  1899. 


Fig.  323.  Alexander  S.  Service  of  Dr.  H.  W.  Gushing.  Osteomyelitis  of  the  tibia.  Lateral 
;ew.  It  will  be  noticed  that  the  bones  of  the  foot  were  outlined  with  unusual  clearness  in  the  radio- 
s  aph  from  which  this  half-tone  was  made,  —  there  has  been  no  retouching,  —  and  that  they  are  more 
;;rmeable  than  normal  to  the  X-rays. 


564    THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

out  difficulty.  The  radiograph  showed  the  bone  to  be  intact,  with  a 
distinct  cortex  and  a  medullary  cavity.  A  part  of  the  shaft  just  above 
the  malleolus  and  of  the  epiphysis  was  lighter  than  elsewhere ;  the  pro- 
cess of  repair  was  delayed  there,  and  probably  the  calcification  was  less 
in  amount.  Dr.  Gushing  concludes  that  the  shaft  of  the  bone  is  more 
easily  restored  than  the  epiphysis.  The  reader  is  referred  to  the  origi- 
nal article  for  details  and  suggestions  in  regard  to  treatment. 

Osteomyelitis  of  the  Tibia. — Alexander  S.,  four  years  old,  entered 
the  hospital  June  5,  1899.  Service  of  Dr.  H.  W.  Gushing.  Three  days 
before  he  had  fallen  on  a  stove  and  injured  his  left  leg.  He  had  a  tem- 
perature of  103!  and  a  pulse  of  no.  On  June  6  operation  was  per- 
formed and  a  considerable  amount  of  dark  brown  pus  escaped  from  the 
incision  along  the  lower  and  inner  side  of  the  tibia.  The  entire  perios- 
teum of  the  shaft  of  the  tibia  was  dissected  away.  The  cavity  left  then 
filled  with  purulent  fluid.  The  shaft  of  the  tibia  was  excised  below  the 
tuberosity  and  above  the  malleolus. 

One  year  later  the  radiographs  (see  Figs.  323,  324),  one  taken  from 
a  lateral  and  the  other  from  an  antero-posterior  point  of  view,  were 
made,  which  show  that  bone  formation  had  taken  place :  — 

Osteomyelitis.  Mary  P.,  seven  years  old  ;  entered  the  hospital  No- 
vember 13,  1900;  patient  of  Dr.  Munro.  Two  weeks  ago  fell  down 
stairs,  bruising  leg,  which  began  to  swell  rapidly  ;  much  pain  and  con- 
stitutional symptoms.  The  patient  is  ancemic.  The  left  leg  presents 
a  marked  enlargement.  X-rays  showed  involvement  of  the  periosteum 
at  the  upper  portion  of  the  tibia  (see  Fig.  325). 

Operation    by   Dr.   Munro    on    November    13,    cavity  curetted  out. 
January    i,    1901,   a   second    operation ;    periosteum   split    down    about 
10  centimetres.     For  7.5  centimetres  the  periosteum  was  lined  with  a 
crackling,  rough,  new  bone  3  to  4  millimetres  thick,  ending  below  in  , 
normal  periosteum.     The  periosteum  with  its  new  bone  was  peeled  from  j 
the  shaft  and  the  shaft  sawn  through  just  below  the  beginning  of  the  | 
normal  periosteum,  and  the  fragment  was  removed.     A  rough  necrotic 
fragment  about  12.5    millimetres    in   diameter  was   removed   from  the  ■ 
epiphyseal  end,  and  the  epiphysis  curetted  wherever  the  bone  seemed 
diseased.      The    edge    of    the    periosteum    was    sutured    with    catgut, 
and  the  leg  compressed  laterally  so  that  the  periosteum  fell  together 
more   or   less    closely.      A  temporary  drain  was   placed   at   the    upper 
end,  the   skin  below  being  sutured.      X-ray  photograph   taken  Janu- 
ary  17,   1 90 1. 


"II     liiif 

Fig.  324.     Alexander  S.     Osteomyelitis  of  the  tibia,     .\ntero-posterior  view. 


Fig.  325.     Mary  P.     Osteomyelitis.     Before  operation.     The  white  sput  seen  in  the  upper  part  of  the 
diseased  area  is  caused  by  an  injury  to  the  negative. 


DISEASES   OF   THE    BONES   AND    OF   THE   JOINTS  567 


Fig.  326.      Mary  P.,  seven  years  old.      Osteomyelitis  of  tibia.      Well  and  diseased  leg  compared. 
Antero-posterior  view.     Radiograph  taken  January  17,  1901,  after  operation. 


568     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


Fig.  327.     Mary  P.     Osteomyelitis  of  tibia.     Lateral  view.     Radiograph  taken  January  17,  1901,  after 

operation. 


Fig.  328.  H.  T.  S.,  fourteen  years  old.  Entered  the  hospital  February  7,  1901.  Osteomyelitis 
of  the  tibia.  Antero-posterior  view.  Operation  done  February  15,  by  Dr.  Paul  Thorndike.  Incision 
over  fluctuation  into  extensive  abscess.    Was  in  the  hospital  in  October,  1900,  with  osteomyelitis. 


Fig.  329.     H.  T.  S.     Osteomyelitis  of  the  tibia.     Lateral  view. 


Fig.  330.  Delora  A.  S.,  eight  years  o!d.  Entered  hospital  January  21,  1901.  Patient  of 
Dr.  Bolles.  Osteomyelitis  of  radius.  Incision  made  in  fluctuating  swelling  over  the  head  of  the 
radius  and  a  considerable  amount  of  pus  evacuated.  X-ray  photographs  made  on  January  22,  1901. 
Antero-posterior  view. 


Fig.  331.     Delora  A.  S.     Osteomyelitis  of  radius.     Lateral  view. 


Fig.  332.  Roy  H.,  fifteen  years  old.  Osteomyelitis;  abscess;  thickened  tibia.  Radiograph 
taken  January  5,  1901.  Antero-posterior  view.  Operation  done  by  Dr.  Burrel',  January  21,  1901. 
Sinus  enlarged ;  no  dead  bone. 


Fig.  333.     Roy  H.     Lateral  view.     Radiograph  taken  January  5,  1901. 


DISEASES   OF   THE    BONES   AND   OF   THE   JOINTS  575 

Tuberculosis  of  the  Bones.  —  Tuberculous  bones,  in  many  cases  at 
least,  are  lighter  than  normal  ones.  The  outlines  of  tuberculous  joints, 
and  especially  the  ends  of  the  bones  near  them,  are  less  defined  than 
normal.  The  cause  of  the  lighter  shadow  appears  to  be  the  result  of 
a  diminished  amount  of  inorganic  salts  in  the  diseased  bones.  This 
subject,  tuberculosis  of  the  bones,  will  be  further  discussed  under 
joints. 

Syphilitic  Disease.  —  Reference  will  be  made  to  the  use  of  the 
X-rays  in  this  disease  under  joints. 

Rickets.  —  This  disease  affects  the  bones  during  development. 
The  proliferation  of  the  cartilage  cells  leads  to  an  enlargement  of  the 
epiphyses,  and  the  cartilage  is  lacking  in  its  normal  amount  of  calca- 
reous matter.  The  X-rays  show  that  in  rickets  the  bones  are  less  dense 
than  normal  and  that  their  shape  is  altered.  A  comparison  of  the  fol- 
lowing analysis  ^  of  the  bones  of  a  healthy  child  two  months  old,  with 
that  of  rachitic  bones,  is  instructive,  and  indicates  why  the  normal  and 
the  rachitic  bones  differ  in  the  shadows  they  produce  on  the  screen  or 
in  the  photograph  :  — 


HEALTHY   CHILD. 

RACHITIC   BOXES. 

Tibia. 

Ulna. 

Femur. 

Tibia. 

Humerus. 

Inorganic  matter     . 
Organic  matter  .     . 
Calcium  phosphate 
Magnesium    .     . 
Calcium  carbonate  . 
Soluble  salt   .     . 
Ossein      .... 

62.3 
34.68 

57 
I 
6 
0.7 

1-3 

64 
35  9 
56 

I 

6 

1.6 

34-9 

I 

20.6 

79-4 

14.7 

0.8 

3 
I 

72 

7 

33-6 
66.3 
26.9  } 

0.8)" 

4.8 

I 
60      } 

6     > 

18.8 
81 

15.6 

2.66 
0.6 

81 

Fats 

n.8 

The  following  cut  was  made  from  an  X-ray  photograph  of  the  foot 
of  a  child  four  years  old,  and  shows  the  rachitic  bones,  the  muscles,  and 
the  adipose  tissue  :  — 

Coxa  Vara.  —  Muirhead  Little  ^  sums  up  his  article  on  this  subject 
by  saying  that  coxa  vara  in  adolescence  may  be  produced  by  the  action 


'  Hallburton's  Physiology. 

2  "Remarks  on  Coxa  Vara,"  British  Medical  Journal,  November  5,  1898,  pp.  I394-I395- 


Fig.  334-     Rickets.     Foot.     From  a  colored  child  four  years  old  (i£ 


578     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

of  gravity  on  bones  softened  by  any  disease ;  that  when  present  in 
children  it  is  due  to  rickets  ;  that  some  cases  of  apparent  coxa  vara  are 
in  reality  curvature  of  the  upper  part  of  the  diaphysis  of  the  femur ; 
others  are  cases  of  dislocation  of  the  hip  ;  and  still  others,  greenstick 
fracture  of  the  cervix  femoris.  The  X-rays  afford,  he  thinks,  the  surest 
means  of  diagnosis  that  we  at  present  possess,  and  should  always  be 
employed.  He  reports  a  case  in  which  the  diagnosis  of  coxa  vara  had 
been  made,  but  in  which  the  radiograph  showed  that  both  hips  were 
dislocated. 

Changes  in  Neck  of  Femur.  —  R.  J.  Godlee^  reports  three  cases  of 
shortening  and  eversion  of  the  lower  extremity  depending  upon  changes 
in  the  neck  of  the  femur,  in  order  to  suggest  that  some  of  the  cases 
described  as  coxa  v^ara  may  be  of  a  different  nature.  Excellent  illustra- 
tive radiographs,  made  by  Mackenzie  Davidson,  are  given  in  the  article. 
Godlee  believes  that  two  of  these  cases  were  the  result  of  tuberculous 
changes  taking  place  in  the  distal  side  of  the  epiphysis  of  the  head  of 
the  bone,  and  he  thought  that  in  one  of  these  two  some  change  had 
also  occurred  in  the  hip-joint  itself. 

Acromegalia.  —  X-ray  photographs  have  been  of  some  service  in  this 
disease  by  pointing  out  changes  in  the  bones. 

Murray^  reports  two  cases  in  which  X-ray  photographs  showed  an 
increased  thickness  of  the  shaft  of  each  of  the  phalanges  of  the  hand, 
the  absence  of  osseous  union  between  the  phalanges  and  the  epiphyses, 
and  a  great  increase  in  the  bulk  of  the  soft  structure  of  the  hands,  and 
in  one  case,  of  the  feet.  Murray  suggests  that  the  union  of  the  epiphy- 
ses may  have  been  arrested  by  some  other  cause  than  the  acromegalia. 

Oudin  and  Barthelemy  have  also  reported  on  the  use  of  the  X-rays  in 
acromegalia. 

New  Growths.  —  New  growths  which  in  any  way  interfere  with  the 
bony  structure,  as,  for  example,  a  growth  which  might  cause  disintegra- 
tion of  the  spinal  column,  may  be  recognized  indirectly  by  an  X-ray 
examination ;  that  is,  the  changes  in  the  bones  could  be  recognized  by 
an  X-ray  photograph,  but  the  cause  of  the  change  would  be  decided  by 
means  of  other  signs  and  symptoms. 

New  growths  which  are  formed  in  the  soft  tissues,  such  as  carci-  i 
noma  and  sarcoma,  have  already  been  referred  to  in  connection  with  the  > 

1  Trans.  Clin.  Soc,  London,  XXXII,  pp.  244-247. 

2  "  Acromegaly  with  Goitre,  and  Exophthalmic  Goitre,"  Edinburgh  Medical  Journal, 
February,  1897,  pp.  170-174. 


Fig.  336.  Osteosarcoma  of  humerus.  Patient  of  Dr.  Bolles  in  1896.  The  fluorescent  screen  and 
radiograph  showed  great  enlargement  of  humerus  and  shaggy  outline.  The  patient  was  lying  on  his 
back  when  the  radiograph  was  taken,  with  the  tube  above  him  and  a  little  inside  the  humerus ;  that 
is,  toward  the  median  line  of  the  body.  Dr.  Bolles  considered  that  this  was  an  osteosarcoma  of  the 
humerus. 


Fig.  337-     Photograph  of  knee.     Mary  K.,  fourteen  years  old.     See  radiograph,  Fig.  338. 


DISEASES   OF   THE    BONES   AND    OF   THE   JOINTS  581 

medical  uses  of  the  X-rays.     Some  of  these  may  affect  the  bones  in 
their  neisrhborhood. 


F'G.  338.     Mary  K.,  fourteen   years   old.      Chondrosarcoma   of  lower  end   of  femur.      Service   of 
Dr.  H.  W.  Gushing.     Radiograph  taken  before  operation. 


582     THE   ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

Differentiation  of  Bony  from  other  Tumors.  —  X-ray  photographs,  as 
well  as  the  fluorescent  screen,  assist  in  differentiating  hard  tumors  which 
are  made  up  of  bony  material  from  those  which  are  not.     I  recall,  for 


Fig.  339.     Mary  K.     Antero-posterior  view.      Disease  beginning  in  phalanx  of  third  finger;    spot 

indicated  by  arrow. 


example,  a  dense,  firm  tumor  of  the  thigh  which  seemed  to  be  connected 
with  the  femur.  While  looking  through  the  fluoroscope,  with  the  fingers 
pressed  against  this  hard  growth,  it  could  be  readily  observed  that  the 
fingers  did  not  come  within  3.5  centimetres  of  the  femur;  that  is  to 


DISEASES   OF   THE    BONES   AND    OF   THE   JOINTS  583 

say,  though  the  tumor  was  firm  and  dense,  it  did  not  contain  any  con- 
siderable portion  of  mineral  salts. 

Chondrosarcoma.  —  Mary  K.,  fourteen  years  old,  entered  the  hospi- 
tal April  10,  1900.     Service  of  Dr.  H.  W.  Gushing.     Six  months  before 


Fig.  340.     Mary  K.    Lateral  view. 

entrance,  without  suffering  any  injury,  or  without  any  apparent  cause, 
she  had  felt  pain  in  the  left  knee,  which  was  aggravated  by  walking. 
About  the  lower  part  of  the  thigh  swelling  was  soon  noticed,  which  in- 
creased ;  pain  constant  and  dull  in  character.  Figure  338  shows  the  out- 
lines of   the  bones  of  the  knee  deUcately  pencilled  (they  are  not  re- 


584     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


Fig.  341.    A.  B.    (Jruuuii\  piioiugrapn  (jI  the  hand  ot  a  man  sixty-seven  years  of  age.    (See  Fig.  342.) 


DISEASES   OF   THE    BONES   AND    OF   THE   JOINTS  585 

touched),  and  that  the  interior  of  the  lower  end  of  the  femur,  the  site  of 
the  disease,  is  very  dark,  but  just  above  this  point  that  the  bone  is  lighter 
than  normal.     The  outline  and  structure  of  the  diseased  area  can  be  easily 


Fig.  342.  A.  B.  Tumor  involving  fingers  of  the  left  hand  of  a  man  sixty-seven  years  old. 
The  tumor  had  existed  for  many  years,  but  was  increasing  slowly  in  size.  It  was  probably  con- 
genital.   This  patient  was  in  the  service  of  Dr.  Gushing.     (Compare  with  Fig,  341.) 


586  THE  ROENTGEN  RAYS  IN  MEDICINE  AND  SURGERY 

followed  in  the  negative,  as  well  as  the  outlines  of  the  muscles  and  ten- 
dons.    Amputation  of  the  upper  fourth  of  thigh,  April  20,  1900. 

Mary  K.     November  21,  1900.    Ring  finger  of  right  hand  has  been 


Fig.  343.     Jacob  I.     Exostosis.     Cut  also  shows  effect  of  this  growth  on  the  next  metatarsal. 
Radiograph  taken  through  bandage. 

inflamed,    swollen,    and    tender.      Fluctuation    detected  to-day ;  to   be 
opened  ;  wearing  a  splint. 

November  22.     Under   anaesthetic  ;  incision  made  over    fluctuation 
and  pus  evacuated. 


DISEASES   OF   THE    BONES  AND   OF   THE   JOINTS         587 

November  26.  Culture  showed  the  infection  to  be  one  of  staphy- 
lococcus. 

December  i.  Incision  of  finger  nearly  healed.  Discharged  to  Con- 
valescent Home. 

Metastatic  Carcinoma.  —  Benedikt^  describes  a  case  of  a  patient  who 
had  had  the  right  kidney  removed  on  account  of  a  cancer,  by  Gussen- 
hauer.  Three  and  a  half  years  afterward  sciatica  set  in,  first  on  the 
right  side  and  later  on  both  sides.  This  pain  was  considered  as  a  new 
illness,  entirely  unconnected  with  the  former  cancer.  But  in  spite  of 
the  treatment  given  the  pain  increased  in  severity.  A  radiograph  was 
then  taken,  which  showed  that  the  last  lumbar  vertebra  was  almost 
entirely  destroyed.  The  diagnosis  of  metastatic  carcinoma  was  thus 
assured.  Benedikt  emphasizes  the  value  of  the  X-rays  in  aiding  the 
physician  to  an  early  diagnosis  in  these  diseases  of  the  vertebras,  and 
states  that  they  present  no  marked  symptoms  for  a  long  time,  but 
if  taken  in  the  early  stage  can  be  more  successfully  treated. 

Joints  and  Cartilages 

Methods  of  Examination.  —  The  joints  in  the  hands  and  feet,  wrists 
and  ankles,  are  most  easily  photographed,  because  they  are  small  and  lie 
near  the  surface,  so  that  the  bones  can  be  brought  close  to  the  plate ; 
other  joints  present  special  difficulties  on  account  of  their  size,  position, 
or  surroundings.  In  the  study  of  the  joints  the  tube  should  be  directly 
above  or  underneath  the  joint  to  be  photographed,  that  is,  opposite  the 
interarticular  space,  in  order  to  show  as  much  as  possible  of  the  outlines 
of  both  bones ;  further,  the  diseased  joint  should  be  compared,  when 
possible,  with  a  normal  one  in  the  same  individual.  Further  directions 
for  examining  joints  have  been  given  in  the  chapter  on  Fractures,  and 
special  methods  for  special  joints  will  readily  suggest  themselves  to  the 
practitioner.  These  tissues  can  be  examined  with  the  best  results  if  a 
new  tube  that  has  a  low  resistance  is  used. 

Tuberculosis  of  Foot.  —  Leslie  E.  P.,  eighteen  years  old,  entered  the 
hospital  May  26,  1899.     Service  of  Dr.  H.  W.  Cushing. 

Diagnosis  :  tuberculosis  of  the  foot. 

History.  —  Four  months  before  lameness  began  in  left  ankle,  possibly 
after  slight  "sprains."  No  swelling  noticed.  Lameness  increased  in 
next  two  months.     Two  months  ago  it  was  put  up  in  plaster-of-paris. 

1  Wiener  klin.  Wochenschrift,  June  8,  1899,  p.  639. 


Fig.  344.  Salvator  C.  twenty-three  years  old.  Tvplioid.  Entered  hospital  September  20,  1900. 
Entered  my  service  October  i.  Arm  examined  with  the  above  result.  Antero-posterior  view. 
E.xostosis  of  ulna  and  radius. 


t  IG.  345.     Salvator  C.     Lateral  view.     i,bj'j  a.;u  i  ij;.  344.J 


590     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


About  this  time  the  patient  had  severe  pain  for  three  days.     QEdema 
about  ankle  ;  no  discharge. 

The  following  X-ray  photographs  were  taken  on  March  27,  1900. 


Fig.  346.     Leslie  E.  P.     March  27,  1900.    Tuberculosis  of  ankle. 


I 


Fig.  347.     Leslie  E.  P.    Tuberculosis  of  foot.    Another  view. 


592     THE    ROENTGEN    RAYS   IN    MEDICINE    AND    SURGERY 

Many  accounts  of  the  usefulness  of  the  X-rays  in  tuberculosis  of  the 
bones  have  been  published,  among  which  the  following  may  be  men- 
tioned as  further  illustrating  this  point :  — 

Lannelongue,  Barthelemy,  and  Oudin  ^  report  a  case  of  tuberculosis 
of  the  first  and  second  phalanx  of  the  middle  finger  of  the  left  hand  in 


Fio.  348.     M.  ].,  child. 


Tuberculosis  of  the  foot.    The  disease  is  chiefly  in  the  first  metatarsal  and 
phalanges.     X-ray  photograph  taken  April  11,  1900. 


which  the  X-rays  confirmed  the  diagnosis.  The  radiograph  showed 
that  a  portion  of  the  second  phalanx  was  lighter  than  normal,  which 
indicated  a  rarefying  osteitis,  and  that  the  space  occupied  by  the  carti- 
lages of  this  articulation  was  greater  than  that  of  the  other  analogous 
joints,  which  indicated  that  the  articulation  was  somewhat  affected,  as 

^  "  De  I'utilite  ties  photographies  par  les  rayons  X  dans  la  pathologic  humaine,"  Compt. 
rend.  Acad.  d.  Sc,  Paris,  1S96,  pp.  159-160. 


DISEASES   OF   THE    BONES   AND   OF   THE   JOINTS  593 


-    ta 


•2.  — 


2  Q 


594 


THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


they  had   supposed.     Dr.  De  F.  Willard  ^  reports  on   three   series  of 
radiographs  (taken  by  Professor  A.  W.  Goodspeed)  of  tuberculous  knees. 
In  the  case  in  the  second  series  the  patient  was  twenty  years  old  and 
had  suffered  from  the  tuberculous  process  for  ten  years.     Radiographs  j 
were  taken  from  four  different  points  of  view.     The  limb  was  fixed  in  a  j 
straight  position,  and  great  erosion  of  the  tibia  and  femur  had  taken  ! 
place ;    therefore  no  attempt    was  made  to  restore  motion  for  fear  a  j 
further  destructive  process  might  be  set  up.     Dr.  Willard  states  that! 
the  value  of  the  X-rays  for  diagnosis  and  as  a  guide  to  treatment  was 
well  illustrated  by  this   series  of  radiographs,  as  well  as  by  the  first 
series  which  he  described.     Levy-Dorn  ^  states  that  cases  have  been 
reported  in  which  small  tuberculous  foci  on  the  spinal  column  of  children 
have  been  observed  in  radiographs.     A.  Oschmann  ^  has  written  an  ex- 
cellent article   on  the  operative  treatment  of  tuberculous  elbow-joints, 
that  is  well  illustrated  by  radiographs,  to  which  the  reader  is  referred. 

Tubercular  Osteitis. — Oudin  and  Barthelemy^  report  on  a  radio- 
graph in  which  areas  of  tubercular  osteitis  could  be  plainly  determined 
in  spite  of  the  swelling  and  suppuration  of  the  surrounding  soft  parts,     j 

Coxitis.  —  Redard  ^  discusses  the  value  of  the  X-rays  in  coxitis,  and 
states  that  they  indicate  in  the  very  beginning  of  the  disease  the  changes' 
that  have  taken  place ;  they  assist  the  observer,  by  showing  the  condition} 
of  the  bones,  to  distinguish  coxitis  from  osteomyelitis  and  from  different; 
kinds  of    arthritis.     In  many  cases  the  radiographs   demonstrate  that 
the  coxitis  has  delayed  the  ossification  of  the  upper  epiphysis  of  the 
femur. 

Caries  of  the  Spine.  —  Noble  Smith,'^  in  1896,  reported  two  cases, 
with  illustrative  radiographs,  in  which  he  had  used  the  X-rays  for  pur- 
poses of  diagnosis.  In  one  case  the  symptoms  had  been  attributed  to 
hysteria,  but  as  they  increased  rapidly  the  patient  was  seen  by  another 
physician,  and  Noble  Smith  was  consulted.  The  latter  believed  that 
there  was  caries  of  the  cervical  vertebrae.     Later  a  radiograph  was  taken 

1  "Roentgen  Ray  Skiagraphs,"  Trans.  Orthop.  .Jissn.,  Philadelphia,  1896,  p.  275. 

2  "  Zur  Kritik  und  Ausgestaltung  des  Roentgenverfahrens,"  Deutsche  Medicinische  Wo- 
chenschrift,  December  9,  1897. 

8  «  Uber  die  operative  Behandlung  des  tuberculosen  Ellenbogengelenkes  und  ihre  Endre- 
sultate,"  Arch.f.  klin.  Chir.,  Berlin,  1899,  LX,  pp.  177-245. 

*  La  France  Medicale,  December,  1896,  p.  807. 

s  Reported  in  Klinisch-therap.  IVochensckr.,  1898,  XXXIV,  p.  1 230. 

6  "  The  Diagnosis  of  Spinal  Caries  by  the  Roentgen  Process,"  British  Medical  Journal. 
June  6,  1896. 


Fig.  350.  Delia  F.  Service  of  Dr.  Post.  Disease  of  the  bones  and  joint,  ]. 
Antero-posterior  view.  The  inner  trochanter  of  the  femur  and  the  same  side  of  the  tibia  are  involved. 
By  comparing  the  inner  half  of  the  articulating  surface  with  the  outer  half,  it  will  be  seen  that  the 
former  is  less  well  defined  than  the  latter. 


596     THE    ROEx\TGEN    RAYS   IN    MEDICINE   AND   SURGERY 

which  showed  the  cervical  vertebrae,  from  the  second  to  the  seventh  in- 
clusive. The  appearance  of  the  bone  demonstrated  the  severity  of  the 
disease  which  had  existed,  and  the  amount  of  repair  that  had  taken 
place.  The  radiograph  cleared  up  all  doubt  as  to  the  nature  of  the 
case,  and  also  indicated  the  line  for  treatment. 

Oudin  and  Barthelemy  ^  have  also  shown  how  useful  the  X-rays  are 
in  indicating  the  extent  of  Pott's  disease  in  children. 

Syphilitic  Diseases.  —  Hahn^  has  published  an  instructive  account 
of  the  work  he  has  done  in  studying  syphilitic  diseases  by  means  of  the 
X-rays. 

In  one  case  the  X-ray  photograph  (taken  by  Dr.  Albers-Schonberg) 
showed  that  the  tumors  on  the  forearm  were  not  connected  in  any  way 
with  the  bones,  but  were  completely  isolated,  and  each  single  tumor 
could  be  made  out  on  the  picture. 

In  a  second  case  the  X-ray  photograph  showed  distinctly  the  thick- 
ening of  the  tibia.     The  patient  was  suffering  from  an  osteosclerosis. 

In  still  another  case  there  was  a  bony  tumor  of  the  humerus,  and 
the  patient  could  only  extend  his  arm  to  an  angle  of  1 50  degrees.  Anti- 
syphilitic  treatment  was  instituted,  and  the  X-ray  photograph  showed 
the  reduction  of  the  tumor,  and  that  the  arm  could  be  moved  through  a 
greater  angle. 

A  fourth  case  was  that  of  a  syphilitic  knee-joint.  The  tumor  was 
almost  as  big  as  the  head  of  a  man,  and  appeared  to  be  a  new  growth.  , 
The  X-ray  examination  showed  that  the  bone  itself  was  only  indirectly  ' 
affected,  but  that  a  periosteal  deposit  nearly  i  centimetre  thick  had 
formed  on  the  bone,  beginning  about  10  centimetres  above  the  knee 
joint,  and  extending  downward  to  the  condylus  internus.  The  outline  of 
the  internal  condyle  was  uneven,  and  its  shadow  was  less  dark  than  that 
of  the  external  condyle.  The  X-ray  photograph  also  indicated  a  large 
exudate  which  had  pressed  the  patella  outward.  Another  radiograph 
taken  during  treatment  showed  improvement  in  all  these  appearances. 

Hahn,3  in  a  report  of  Roentgen  ray  work,  gives  a  case,  described  by 
Stamm,  of  a  boy  a  year  old.  Stamm  ascribed  the  multiple  thickening 
of  the  different  long  bones  to  syphilitic  disease  of  the  epiphyseal  carti- 
lage, but  the  X-ray  photograph  showed  nothing  abnormal  in  the  bones ; 
the  structure  was  plainly  to  be  seen. 

1  La  France  Medicale,  December,  1896,  p.  807. 

'■^  Fortschrilie  a.  d.  Geb.  d.  Koentgentsir.,  B.  II,  pp.  132-135. 

^  Ibid.,  p.  190. 


DISEASES   OF  THE    BONES   AND   OF   THE   JOINTS         597 

Albers-Schonberg  ^  reports  on  four  pictures  of  syphilitic  disease  of 
the  joints  showed  by  Katzenstein;  one  of  syphiUtic  dactylitis  and  three 
of  diseases  of  knee-joints. 


JFlC.  351.     Rheumatoid  arthritis  of  third  finger  joint  indicated  by  arrow.      The  space  between  the 
I  phalanges  is  not  as  clear  as  it  is  in  the  corresponding  joint  of  the  middle  finger. 

i  1  Fortschritte  a.  a.  Geb.  d.  Roentgenstr.,  B.  Ill,  p.  35. 


598     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Rheumatoid  Arthritis.  —  The  preceding  radiograph  shows  the  appear- 
ances seen  in  this  disease. 

Osteo-arthritis  of  the  large  joint  of  the  great  toe.  This  caused  much 
pain  unless  boots  adapted  to  the  foot  were  worn.     (See  Fig.  353.) 

Cartilage.  —  In  most  radiographs  of  the  joints  we  find  a  space 
between  the  ends  of  the  bones  under  normal  conditions,  but  when 
the  articular  cartilage  has  been  thinned,  or  is  absent,  the  bones  are 
not  thus  separated.  Articular  cartilage  has  a  composition  between 
the  soft  and  hard  tissues,  represented  by  muscle  on  the  one  hand  and 
bone  on  the  other,  and  we  should,  therefore,  in  conditions  involving  the 
cartilage,  take  more  than  one  radiograph,  and  make  one  of  the  ex- 
posures with  a  view  to  getting  a  picture  of  the  cartilage,  or  of  determin- 
ing its  altered  condition  or  absence.  These  tissues  can  be  examined 
with  the  best  results  if  a  new  tube  that  has  a  low  resistance  is  used. 

Hyaline  Cartilage. — The  shadow  of  this  cartilage  may  vary,  as  in 
age  it  may  become  calcified  or  ossified. 

Loose  Cartilage.  —  Loose  cartilages  are  generally  of  hard  fibrous  or 
partly  bony  tissue.  They  show  in  the  radiograph,  but  not  as  distinctly 
as  bone  (Fig.  352). 

Cartilages  affected  by  Gout.  —  In  this  disease  crystalline  urates 
(sodic  urate)  are  deposited  in  the  cartilage  and  elsewhere,  and  they 
may  be  seen  in  the  radiograph  outside  the  joint. 

In  some  cases  the  sodium  urate,  acting  as  a  foreign  body,  may  set 
up  an  inflammation,  and  become  infiltrated  with  calcium  phosphate,  as 
tuberculous  matter  often  is ;  calcium  urate  may  also  be  found ;  the 
composition  of  the  cartilage  being  thus  changed,  it  would  show  even 
more  clearly  in  the  radiograph. 

Flat  Foot. — (See  Fig.  354.)  B.  H.,  eighteen  years  old.  Service  of 
Dr.  Bolles.  This  patient  had  had  pain  in  the  sole  of  his  right  foot  for 
about  two  months,  after  standing  or  walking  for  some  time.  He  had 
had  no  injury,  and  was  otherwise  well.  An  operation  was  performed, 
and  he  was  discharged  relieved. 

Bony  and  Fibrous  Ankylosis.  —  Osseous  ankylosis  can  be  distin- 
guished from  fibrous  ankylosis  by  means  of  the  X-rays ;  the  radiograph 
shows  in  the  former  that  the  interarticular  space  is  obliterated. 

Osseous  Ankylosis.  —  Mr.  Sidney  Rowland  ^  inserts  in  his  report  to 
the   British  Medical  Journal  the   following   case   of  osseous  ankylosis 

1  "  Report  on  the  Application  of  the  New  Photography  to  Medicine  and  Surgery,"  by 
Sidney  Rowland,  British  Medical  Journal,  1896,  Vol.  I,  pp.  496-497.  \ 


Fig.  352.     Loose  caitiiage  in  knee-joint. 


6oo     THE    ROENTGEN    RAVS    IN    MEDICINE    AND    SURGERY 

which  was  treated  by   Dr.   B.  L.  Abrahams,  and  of  which   Mr.  Sidney 
Rowland  took  the  radiographs  :  — 

The  patient,  V.  F.,  a  youth  of  nineteen,  injured  his  right  little  finger 
while  attempting  to  catch  a  cricket  ball.     As  a  result  of  this  accident, 


Fig.  353.     Osteo-arthritis  of  great  toe  joint. 


the  last  joint  of  this  finger  was  bent  at  a  sHght  angle,  and  was  fixed  in! 
this   position,  allowing   neither  flexion   nor   extension.     This  condition 
prevented  the  patient  from  completely  closing  his  fist,  and  any  force 


6o2     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

transmitted  through  the  bones  of  the  finger  caused  great  pain.  He 
was  treated  at  the  out-patient  department  of  a  hospital  in  London  for 
some  little  time,  and  was  then  told  that  the  phalanges  had  been  frac- 
tured, that  the  joint  was  firmly  ossified,  and  that,  to  obtain  relief,  ampu- 
tation of  the  phalanx  was  necessary.  The  patient  then  went  to  Mr. 
Rowland,  who  made  a  radiograph  of  the  finger,  and  he  and  Dr. 
Abrahams  concluded  that  the  two  last  phalanges  were  connected  by 
a  bridge  of  bone  which  had  been  thrown  out,  owing  to  the  traumatic 
inflammation  of  the  joint.  Dr.  Abrahams  broke  the  bridge,  and  a 
radiograph  taken  after  the  operation  showed  that  the  two  phalanges 
were  no  longer  connected.  In  this  case  the  X-rays  indicated  the  line 
of  treatment  by  showing  that  the  ankylosis  was  only  partial,  not  total. 

It  is  evident  that  the  X-rays  afford  a  means  of  recognizing  chemical 
changes  that  have  taken  place  in  the  body.  We  should  therefore  use 
every  effort  to  study  with  the  greatest  care  any  conditions  or  diseases 
involving  such  a  change,  for  a  knowledge  of  it  will  aid  us  in  making  a 
diagnosis,  and  possibly  enable  us  to  anticipate  the  subsequent  changes 
which  are  physical  in  character. 

The  X-rays  will  continue  to  become  of  more  value  for  examining 
diseases  of  the  bones  and  joints  as  the  apparatus  improves,  because 
with  better  apparatus  will  come  greater  possibilities  in  the  way  of  dif- 
ferentiation ;  their  value  in  these  diseases  will  also  increase  as  the 
practitioner  learns  to  interpret  better  what  the  radiograph  presents. 


CHAPTER   XXIII 

DENTAL  SURGERY 

For  the  successful  use  of  the  X-rays  in  dentistry,  sharp  definition  in 
negatives  is  necessary,  and  differentiation  is  required  between  tissues 
that  do  not  differ  very  much  in  the  obstruction  they  offer  to  the  passage 
of  the  X-rays.  The  roots  of  the  teeth  are  only  a  little  less  permeable 
to  the  rays  than  the  surrounding  bone,  and  therefore  it  is  difficult  to  get 
a  clear  picture  of  their  ends. 

Suitable  Apparatus 

Generator.  —  The  A.  W.  L.  Universal  coil  with  the  Heinze  inter- 
rupter is  a  good  apparatus  for  taking  photographs  of  the  teeth.  The 
current  obtained  is  unidirectional  and  steady,  and  steadiness  of  the 
radiant  area  is  essential  when  taking  photographs  of  such  small  objects. 

Tube.  Sharp  Definition.  —  To  insure  good  definition  the  cathode 
stream  must  be  sharply  focussed  on  the  target,  as  this  secures  a  small 
radiant  area  from  which  the  X-rays  arise.  A  suitable  tube  for  X-ray 
work  is  shown  in  Fig.  26,  page  36.  The  stems  of  the  anode  and 
cathode  are  bare  and  of  sufficient  size  to  stand  hard  use  without  being 
bent  out  of  line.  The  cathode  is  drop-forged  to  an  exact  curvature  and 
the  concave  face  is  perfectly  smooth  ;  defects  in  this  surface  alter  the 
cathode  stream  and  thus  make  the  radiant  area  of  the  target  larger, 
with  the  result  that  the  definition  of  the  picture  is  not  so  sharp.  The 
target  is  of  platinum  alloyed  with  iridium ;  the  stem  is  hollow  and 
cooled  artificially  (see  Chapter  II,  page  35),  and  therefore  the  cathode 
stream  can  be  sharply  focussed  on  its  face  without  danger  of  melting 
the  metal.  The  angle  is  56°  instead  of  45°,  and  thus  the  apparent 
radiant  area  is  made  smaller  in  its  longest  diameter  and  approaches 
more  nearly  to  a  circular  form. 

Resistance.  —  For  good  differentiation  between  tissues  that  are  not 
very  different  in  permeability  the  tube  must  have  a  low  resistance. 
Methods  for  lowering  the  resistance  when  it  has  become  too  high,  and 

603 


6o4    THE    ROENTGEN   RAYS   IN    MEDICINE   AND   SURGERY 

obtaining  again  the  proper  quality  of  light,  have  been  stated  in  Chapter 
II,  page  44.  The  following  cut  (see  Fig.  355)  shows  the  oven  there 
mentioned.  It  has  asbestos  ends  CC,  through  which  pass  the  terminals 
DD.  It  is  heated  by  the  burners  HH,  the  effect  of  the  heat  on  the  tube, 
which  is  supported  by  asbestos  slabs  A  A,  being  observed  through  a 
transradiable  door.  The  heat  liberates  the  gas  from  the  glass  walls  of 
the  tube.     But  all  methods  of  lowering  the  resistance  are  temporary. 

Rollins  believes  that  one  cause  of  the  rise  in  the  resistance  of  a  tube 
is  due  to  a  diminished    supply  of   gas  particles  in  the  terminals,  and 


Fl^-  355-     Oven  for  heating  tube,  thereby  hberating  gas  from  its  walls  and  loweiing  its  resistance. 


that  it  is  a  necessary  result  of  use.  He  therefore  considers  that  to 
reduce  this  resistance  some  method  should  be  devised  to  restore  these 
gases  to  the  terminals. 

Tube-holder  and  Diaphragm.  —  In  addition  to  a  suitable  apparatus 
and  tube  for  producing  a  small  and  steady  radiant  area,  it  is  essential 
for  obtaining  the  best  definition  to  so  enclose  the  tube  that  no  X-rays 
can  escape  except  the  smallest  cone  that  will  cover  the  area  to  be  photo- 
graphed. Figure  42,  Chapter  II,  page  52,  shows  a  suitable  tube-holder 
with  cover  removed,  and  Fig.  356  shows  the  cover  and  diaphragm  in 
place. 


DENTAL   SURGERY  605 

Screen. — While  taking  radiographs  of  the  teeth  it  is,  of  course, 
important  to  avoid  danger  of  burns  ;  an  aluminum  screen,  grounded,  as 


Fig.  356.     Apparatus  m  position  for  photographing  upper  front  teeth. 

suggested  by  Tesla,  should  therefore  be  used  (see  Chapter  II,  page 
58).  A  good  form  of  screen  for  dental  photography  is  shown  m 
Fig    356.     It  consists    of  a  framework   of  wood  sliding  on  the  tube- 


6o6     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

holder.  To  this  is  attached  a  disk  of  tin  43  centimetres  in  diameter,  in 
the  middle  of  which  is  a  square  hole  10  centimetres  in  diameter.  Three 
sides  of  the  square  surrounding  the  hole  are  grooved,  and  in  these 
grooves  sUdes  a  sheet  of  aluminum  or  a  screen  of  aluminum  wire.  The 
latter  is  the  more  convenient,  as  it  allows  the  ordinary  light  as  well  as 
the  X-rays  to  pass  on  to  the  patient,  and  shows  to  the  eye  the  area 
covered  by  the  cone  of  X-rays  escaping  from  the  tube-holder. 

Position  of  Patient.  —  Figure  356  shows  the  general  arrangement  of 
the  apparatus  for  taking  a  photograph  of  the  upper  front  teeth. 

Position  of  Plate  or  Film.  —  Glass  plates  are  less  useful  than  films 
for  photographing  the  teeth.  The  method  in  general  use  in  this  coun- 
try was  devised  by  Dr.  Rollins  in  1896.  It  consists  in  placing  inside 
the  mouth  the  sensitive  films,  which  have  previously  been  enclosed  in 


CELLULOID    FILMS. 


RUBBER  BA( 


i  (closed) 


RUBBER  BAS   .:P£: 


RETAINING    CLIP 

HALF    SIZE. 


Fig.  357.     Films  for  photographing  teeth.     To  be  placed  inside  the  mouth.     Method  devised  by 

Dr.  Rollins  in  i8q6. 


V 


a  thin  bag  of  black  soft  rubber  or  black  waterproof  paper,  to  exclude 
hght  and  moisture,  and  in  putting  the  tube  opposite  the  same  jaw  as 
the  films  and  about  28  centimetres  distant  from  them.  Several  films, 
each  one  separated  by  a  thin  sheet  of  foil,  are  used,  because  in  this 
way  each  negative  has  a  slightly  different  exposure.  The  film-holder 
is  shown  in  Fig.  357. 

For  some  cases  the  metal  film-holder  shown  in  Fig.  358  is  desirable. 

Length  of  Exposure.  —  The  length  of  exposure  depends  upon  the 
amount  of  light,  and  varies  from  a  few  seconds  to  several  minutes, 
according  to  the  form  of  apparatus  used. 

The  main  uses  of  the  X-rays  in  dentistry  are  as  follows :  — 

1.  To  obtain  information  about  unerupted  teeth. 

2.  To  find  the  position  of  roots  before  regulating,  or  for  bridge  work. 

3.  To  recognize  pulpless  teeth. 


DENTAL   SURGERY 


607 


Fig.  358. 


Metal  film-holder 


To  determine  the  presence,  cause,  and 
extent  of  alveolar  abscess. 

To  discover  the  extent  of  alveolar 
absorption  in  chronic  loosening  of 
the  teeth. 

To  detect  fractures  of  roots  caused 
by  blows  or  falls. 

To  find  whether  a  root  canal  has  been" 
filled. 

To  find  fluid  in  the  antrum. 

I.  Unerupted  Teeth.  —  The  X-rays 
give  us  information  in  regard  to  unerupted 
teeth  not  easily  obtained  in  any  other 
way.  This  information  may  be  desired 
for  the  following  purposes  :  — 

(a)  Absence  or  Presence  of  Permanent 
Teeth.  —  The  most  frequent  need  is  to 
determine  whether  or  not  there  is  a  per- 
manent tooth  in  the  jaw,  in  those  cases 
in  which  a  temporary  tooth  is  retained 
beyond  the  normal  age.  If  such  a  tooth 
is  found,  and  is  of  normal  shape,  and  in 
a  position  to  erupt,  the  temporary  tooth 
should  be  removed ;  if  the  permanent 
tooth  is  deep  in  the  jaw,  the  following 
method  devised  by  Dr.  Rollins  should  be 
employed.  This  method  consists  in  cut- 
ting down  with  one  of  his  tubular  knives 
until  the  tooth  is  reached ;  a  mechanical 
appliance  is  then  adjusted  which  prevents 
the  neighboring  teeth  from  closing  up 
the  gap  made  by  the  removal  of  the 
temporary  tooth,  and  at  the  same  time 
exerts  traction  upon  the  unerupted  tooth. 

{b)  Neuralgia.  —  Another  important 
use  of  the  X-rays  in  this  direction  is  the 
detection  of  unerupted  teeth  that  are 
causing  neuralgia.  It  is  not  uncommon 
for  teeth,  particularly  lower  third  molars, 


6oS     THE    ROENTGEN    RAYS    IN    MEDICINE   AND   SURGERY 

to  be  imbedded  in  the  jaw  in  such  a  position  that  they  cannot  come 
through,  and  therefore  become  the  seat  of  obstinate  pain.  The  treat- 
ment in  such  cases  is  to  remove  the  given  tooth  ;  or,  if  this  removal 
involves  too  serious  an  operation,  to  remove  the  tooth  which  prevents 
the  eruption.  Dr.  Rollins  has  found  that  teeth  which  the  X-rays  show 
to  be  lying  at  right  angles  to  their  normal  position,  will  turn  through 
an  angle  of  90  degrees,  erupt  in  proper  position,  and  then  advance 
into  the  space  left  free  by  extraction  until  they  fill  it ;  a  process  to 
which  he  has  given  the  name  of  "  progression  in  teeth." ) 


Fig.  359.  Patient  of  Dr.  Clapp.  Age 
twenty-one ;  male.  Shows  unerupted  cuspid 
very  liigh  up  and  over  second  bicuspid.  Also 
portion  of  antrum. 


Fig.  360.  Patient  of  Dr.  Clapp.  Shows 
unerupted  cuspid,  but  no  trace  ot  lateral. 
Temporary  cuspid  in  place. 


Fig.  361.  Patient  of  Dr.  Price.  Radio- 
graph of  the  superior  front  teeth  of  a  boy  eight 
years  of  age.  His  mother  and  grandmother 
had  lacked  the  permanent  laterals,  and  it  was 
feared  he  would  also,  and  steps  were  being 
taken  to  prevent  the  first  being  shed,  when  the 
radiograph  was  taken,  which  shows  clearly  that 
the  boy  will  get  his  permanent  laterals. 


Fig.  362.  Patient  of  Dr.  Price.  Shows  the 
superior  arch,  in  which  no  teeth  have  been 
erupted,  of  a  boy  fourteen  months  of  age.  Not 
only  are  all  the  teeth  of  the  temporary  set 
shown  in  the  negative  of  the  radiograph,  but 
the  negative  also  shows  that  the  central  incisors 
of  the  permanent  set  are  forming  and  that  the 
crypts  are  started  for  the  permanent  laterals, 
which  teeth  his  father  has  never  had. 


DENTAL   SURGERY 


609 


Fig.  363.  Palienl  ot  Dr.  Clapp.  Shows 
the  structure  of  the  bone,  the  floor,  and  consid- 
erable portion  of  the  antrum.  It  was  taken  to 
ascertain  if  there  was  an  impacted  third  molar, 
none  having  ever  erupted. 


Fig.  364.  Patient  ol  Dr.  Clap|).  (Age 
fifteen.)  Left  superior  temporary  central  and 
cuspid  still  in  place.  Taken  to  ascertain  if  the 
permanent  central  was  in  the  jaw.  X-ray 
photograph  shows  it,  and  also  that  the  apex  of 
root  is  stiil  unformed. 


Fig.  365.  Patient  of  Dr.  Clapp.  Shows 
crown  of  unerupted  third  inferior  molar  com- 
pletely within  the  jaw.  Alveolar  and  gum  line 
shown  in  cut. 


Fig.  366.  Patient  of  Dr.  Clapp.  (F"ifleen 
seconds'  exposure.)  Taken  to  ascertain  if  a 
root  of  the  first  molar  remained  unerupted. 
Shown  to  impmge  on  root  of  second  molar. 
(Superior.) 


Figs.  367,  368.  Patient  of  Dr.  Price.  Show  both  sides  of  the  superior  arch  of  a  girl  of  twelve 
years  of  age,  who  has  retarded  dentition.  They  show  very  clearly  the  relation  of  the  temporary 
molars  to  the  bicuspids  which  are  forming  above  them. 


6lO     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 


Fig.  369.  Patient  of  Ur.  Clapp;  girl,  aged 
thirteen.  Shows  temporary  left  lateral.  The 
permanent  central,  with  apex  unformed,  is 
within  the  jaw  above  the  temporary  central. 
Shows,  also,  portion  of  nasal  cavity. 


Fig.  370.  Patient  of  Dr.  Price.  Shows  a 
case  of  delayed  dentition.  A  girl  at  seventeen 
years  of  age  still  has  her  temporary  cuspid,  with 
no  indication  that  the  permanent  has  ever 
formed.  The  radiograph  shows  it  to  be  im- 
bedded against  the  central  at  an  angle  of  about 
forty-five  degrees.  It  is  now  being  placed  in 
its  proper  position.  The  gold  of  a  crown  is 
conspicuously  shown  on  the  next  tooth. 


Figs.  371,  372.  Patient  of  Dr.  Price.  Show  the  front  part  of  the  superior  arch  of  a  boy  at  four- 
teen years  of  age.  He  has  still  his  temporary  cuspids  and  the  right  temporary  lateral.  The  centrals 
have  been  regulated.  Clearly  the  boy  is  never  to  have  his  permanent  laterals,  but  will  in  time  get  his 
permanent  cuspids. 


Figs.  373,  374.     Patient  of  Dr.  Clapp.     Woman,  age  twenty-three.     Temporary  cuspids  in  place,  with 
the  unerupted  permanent  ones  lying  nearly  horizontally  within  the  jaw. 


DENTAL   SURGERY 


6ll 


Fig.  375.  Patient  of  Dr.  Clapp.  Girl,  age 
about  fourteen.  Shows  deformed  left  lateral 
and  the  left  central  imbedded  and  horizontal 
in  the  jaw. 


Fig.  37(3.     I'atit^nt   ul    Dr.   Clapp.     Alalplaced 
inferior  third  molar. 


2.  Position  of  Roots. — (See  Fig.  377.)  (a)  Before  regulating  teeth  it 
is  often  desirable  to  know,  not  only  the  position  of  their  roots,  but  also 
to  what  extent  they  are  closed.  If  the  apex  of  the  root  is  not  fully 
formed,  the  teeth  can  be  regulated  more  rapidly  without  danger  of 
destroying  the  pulp.  The  X-rays  often  give  valuable  information  in 
regard  to  some  tooth  which  it  is  desired  to  move ;  this   process  is  not 


Fig.  377.  Patient  of  Dr.  Clapp.  Shows 
curved  root  of  lateral,  demonstrating  why  there 
was  difficulty  in  rotating  it. 


Fig.  378.  A  piece  of  bridge  work  in  posi- 
tion, resting  on  cuspid  and  lateral  roots.  The 
picture  was  talcen  to  ascertain  the  probable 
strength  of  the  lateral  root.  It  is  shown  to  be 
very  short  and  with  but  slight  alveolar  attach- 
ment. 


infrequently  impracticable  owing  to  some  malformation  of  the  root,  but 
before  the  discovery  of  the  X-rays  time  was  sometimes  lost  in  vain 
attempts  to  bring  such  a  tooth  into  place,  (d)  A  knowledge  of  the 
position  of  the  roots  is  desirable  for  bridge  work.     (See  Fig.  378.) 

3.  Diagnosis  of  Pulpless  Teeth. —  The  pulp  chamber  in  a  pulpless 
tooth  shows  more  clearly  on  the  negative  than  the  living  pulp,  but  this 
diagnosis  can  usuallv  be  made  with  ease  without  the  use  of  the  X-rays. 


6l2     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


4.  Alveolar  Abscess.  —  The  death  of  the  pulp  is  often  followed  by 
an  abscess.  This  abscess  is  usually  due  to  imperfect  manipulation,  but 
as  the  roots  are  small  and  irregular  it  is  not  always  possible  to  fill  them 
to  the  ends.  As  a  result,  an  abscess  may  develop.  The  X-rays  would 
show  the  extent  of  this  abscess. 

Broken  Instninicnt. — (See  Figs.  382,  383.)  In  preparing  the  roots 
for  filling,  instruments  are  frequently  broken  without  the  knowledge  of 
the  dentist,  or  if  he  is  aware  of  the  fact  and  attempts  their  removal,  they 

may  be  forced  through  the  ends  of  the  roots. 
The  X-rays  show  that  such  conditions  are 
frequent,  and  indicate,  first,  the  importance  of 
using  untempered  instruments  made  of  piano 
wire  for  all  work  on  root  canals  ;  and,  second, 
the  position  of  the  piece  of  instrument  if  the 
accident  has  occurred,  and  thus  enable  the 
operator  to  take  suitable  measures. 

Origin  of  Abscess.  —  It  is  not  always  easy 
to  determine  the  point  of  origin  of  the 
abscess,  for  sometimes  an  alveolar  abscess 
does  not  appear  to  take  the  shortest  path  to 
the  surface.  The  X-rays  make  it  possible 
to  determine  its  origin  and  in  consequence 
make  the  treatment  more  simple.  With  the 
information  given  by  the  X-rays  this  incision 
can  be  made  directly  over  the  abscess,  and  thus  the  least  loss  of  tissue 
possible  is  involved. 


Fig.  379.  Patient  of  Dr.  Price. 
Shows  an  abscess  of  eight  years' 
standing.  It  has  formed  at  the 
apex  of  the  superior  lateral  inci- 
sor, and  has  developed  a  cavity 
in  the  bone  as  large  as  a  hickory 
nut. 


Fir,.  380.  Patient  of  Dr.  Price.  Shows  the 
extent  of  an  abscess  of  the  lower  jaw  which 
has  half  cut  the  jaw  in  two. 


Fig.  381.  Patient  of  Dr.  Price.  Shows 
the  appearance  of  the  early  stage  of  an  abscess 
at  the  apex  of  a  root. 


DENTAL   SURGERY 


613 


Figs.  382,  383.  Patient  of  Dr.  Clapp.  Broken  instrument  in  the  jaw.  The  instrument  was 
forced  through  the  central,  and  remained  in  the  jaw  a  year,  causing  serious  abscess.  These  two  cuts 
sliow  the  great  liability  to  error  in  diagnosis  from  X-ray  pictures  unless  two  views  are  taken.  One 
of  the  cuts  represents  the  instrument  as  protruding  from  the  apex  of  the  central ;  the  other,  that 
it  lies  between  the  central  and  lateral.     The  latter  was  the  true  position. 


5.  Extent  of  Alveolar  Absorption.  —  The  X-rays  are  not  necessary  to 
show  the  presence  of  alveolar  absorption,  which  is  sadly  evident  and 
impossible  of  cure,  but  it  is  of  interest  to  know  the  extent  of  the  loss. 
Dr.  Rollins  has  shown  by  means  of  the  X-rays  an  absorption  of  the  edge 
of  the  alveoli  in  mouths  where  there  was  no  out- 
ward sign  of  the  disease. 

6.  Fractured  Roots. — (See  Fig.  384.)  It  has 
been  impossible  by  the  older  methods  to  make  a 
diagnosis  of  a  fracture  of  the  upper  end  of  a  root, 
and  therefore  impossible  to  learn  whether  or  not 
such  fractures  would  heal.  It  has  been  customary 
to  believe  that  dentine  had  no  power  of  repair. 
Dr.  Clapp,  however,  has  observed  by  the  X-rays 
a  fracture  which  did  not  show  in  subsequent  nega- 
tives, and  although  he  does  not  consider  such 
evidence  conclusive,  it  is  nevertheless  interesting. 

7.  Root  Canal  filled  or  not.  —  It  is  often  desirable  to  know,  without 
removing  a  filling,  whether  or  not  a  root  canal  has  been  filled,  and  this 
information  can  be  furnished  by  the  X-rays  even  when  the  filling  is  not 
of  metal,  for  the  oxide  of  zinc  used  in  the  non-metallic  fillings  is  less  per- 
meable by  the  rays  than  the  dentine. 

8.  Fluid  in  the  Antrum.  —  Fluid  can  be  seen  in  the  antrum  by  ordi- 
nary light,  therefore,  although  the  X-rays  can  be  used,  to  determine  the 
presence  or  absence  of  this  fluid,  they  are  not  likely  to  supersede  the 
present  method. 

Interpretation  of  X-Ray  Pictures.  —  It  is  easy,  as  already  stated,  to 
draw  incorrect  inferences  from  X-ray  negatives.     Figures  382  and  383, 


Fk;.  384.  Patient  of 
Dr.  Clapp.  Shows  lower 
incisor  broken  near  apex 
by  blow  from  a  polo  mallet. 


6 14     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

made  from  the  same  case,  illustrate  this  fact :  in  Fig.  382  the  broken 
steel  instrument  appears  to  project  from  the  end,  in  Fig.  383  from  the 
side,  of  the  root. 

Further,  unless  care  is  taken  to  place  the  light  and  the  plate  in 
proper  relation,  distortion  will  occur  and  very  erroneous  conclusions 
may  be  drawn.  By  practice  alone  can  accurate  results  be  obtained. 
In  a  general  way  it  may  be  said  that  it  is  desirable  to  keep  the  plane  of 
the  film  perpendicular  to  the  central  rays  and  parallel  with  the  long 
axis  of  the  teeth  to  be  photographed. 

I  am  indebted  to  Dr.  Dwight  M.  Clapp  of  Boston  and  to  Dr.  Weston 
A.  Price  of  Cleveland  for  the  radiographs  from  which  the  cuts  of  the 
teeth  were  made. 

I  am  also  indebted  to  Dr.  Rollins  for  his  kindness  in  obtaining  these 
radiographs  and  providing  the  cuts;  likewise,  for  the  material  contained 
in  this  chapter,  and  for  the  cuts  marked  with  his  name  in  this  chapter 
and  in  Chapters  II  and  XXIV. 

Dr.  Rollins  was  among  the  first  to  appreciate  the  importance  of 
Roentgen's  discovery  to  medicine,  and  his  genius  for  devising  new  forms 
of  apparatus  has  already  been  illustrated  in  the  chapter  on  X-ray  equip- 
ment. His  contributions  to  a  better  knowledge  of  the  physics  of  the 
cathode  rays,  the  progenitors  of  the  X-rays,  are  well  known. 


CHAPTER   XXIV 

CALCULI 

The  ease  with  which  calculi  can  be  recognized  by  the  X-rays 
depends  upon  their  size  and  chemical  composition.  The  importance 
of  this  latter  factor  is  illustrated  by  an  experiment  which  I  made  in 
1896. 

Before  trying  to  take  X-ray  photographs  1  of  calculi  in  the  body,  I 
placed  several  different  kinds,  together  with  other  objects,  on  a  photo- 
graphic plate,  and  added  to  these  a  cup  of  water  as  a  standard  of  com- 
parison. The  result  is  seen  in  Fig.  385.  It  will  be  readily  appreciated, 
from  a  glance  at  this  illustration,  that  calculi  similar  in  size  will  be 
recognized  more  or  less  easily  according  to  the  amount  of  inorganic 
salts  contained  in  them,  as  those  made  up  largely  of  organic  matter 
cast  a  much  fainter  shadow  than  those  consisting  mostly  of  inorganic 
substances. 

The  difficulty  of  recognizing  calculi  made  up  of  pure  uric  acid  is 
further  illustrated  by  the  following  test:  — 

I  took  a  kidney  which  had  been  hardened  in  formalin  and  which 
contained  uric  acid  calculi  and  small  cysts,  and,  placing  it  on  a  photo- 
graphic plate,  exposed  it  to  the  X-rays.  After  the  plate  was  developed 
there  was  no  trace  of  the  small  uric  acid  calculi  or  of  the  full  cysts,  but 
the  outline  of  the  cavities  which  had  been  made  by  cutting  open  and 
emptying  some  of  the  cysts  could  be  seen  on  the  plate.  The  calculi 
were  from  3  to  6  millimetres  in  diameter,  and  the  cysts  varied  from 
about  12  to  15  millimetres  in  diameter. 

Thus,  in  the  kidneys,  bladder,  or  gall  bladder,  we  may  expect  to  detect 
calculi  by  the  rays  when  they  contain  inorganic  matter,  that  is,  mineral 
substances,  such  as  the  salts  of  calcium  ;  but  if  they  are  made  up  wholly 

1  When  such  X-ray  photographs  are  made  it  is  well  to  include  a  receptacle  holding  a 
measured  depth  of  water,  as  shown  in  the  cut,  otherwise  the  comparison  may  be  misleading  ; 
for  by  using  a  short  exposure  we  may  easily  make  a  negative  which  would  suggest  that  the 
objects  photographed  were  not  easily  penetrated. 

615 


6i6     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 


mn 


Fig.  385.  Experiment  made  in  1896.  The  two  upper  rows  of  objects  in  this  radiograph  are 
calculi.  The  two  calculi  on  the  left  are  composed  of  uric  acid  and  urates  ;  those  on  the  right,  of  phos- 
phates ;  and  the  two  in  the  middle,  of  oxalate  of  calcium  and  uric  acid,  the  upper  one  of  these  last  two 
having  an  outside  coating  of  urates.  In  tlie  centre  of  the  picture  is  a  round  aluminum  cup,  contain- 
ing water,  2.5  centimetres  in  depth,  and  on  either  side  of  this  cup  is  a  group  of  gall  stones,  and  to  the 
right  and  below  the  cup  a  single  large  gall  stone  is  seen  indistinctly.  In  the  left-hand  lower  corner  is 
a  decalcified  bone,  bent  into  the  shape  of  D,  with  a  lead  tag  attached  by  a  copper  wire.  The  decalci- 
fied bone  surrounds  an  incinerated  bone,  which  is  l>'ing  on  a  piece  of  cotton  wool  in  a  wooden  box 
with  a  glass  side.  In  the  right-hand  lower  comer  is  a  dry  bone;  in  the  extreme  right-hand  corner  is 
a  triangular  piece  of  lead.     The  picture  is  reduced  to  one-third  of  its  original  size. 


CALCULI  617 

of  organic  matter  I  think  they  can  be  photographed  only  with  difficulty, 
because  stones  made  up  of  uric  acid  are  penetrated  by  the  rays  about 
as  easily  as  the  soft  tissues  of  the  body. 

Ringel  ^  stated  that  oxalates,  urates,  and  phosphates  stood  in  the  order 
named  as  regards  the  obstruction  they  offered  to  the  passage  of  the  X-rays, 
oxalates  being  the  most  opaque.  On  further  investigation,  however,  he 
found  that  the  uric  acid  stone  he  had  photographed  contained  traces  of 
oxalate  of  calcium,  and  that  a  pure  uric  acid  stone  was  more  trans- 
parent than  the  phosphatic,  that  is,  the  most  transparent  of  all  the  three 
substances. 

He  thought  that  phosphatic  calculi  were  the  most  common,  that  is 
to  say,  in  his  collection  he  has  three  oxalate  stones,  three  uric  acid, 
and  eleven  phosphatic  stones.  Other  observers,  however,  find  the  uric 
acid  or  urates  to  be  the  most  common  form.  It  is  possible,  therefore, 
that  the  conditions  of  the  place  in  which  the  patient  resides  determine 
to  some  extent  the  composition  of  the  calculi. 

Appearances  seen  on  the  X-Ray  Photograph.  —  The  following  cut  is 
illustrative  (see  Fig.  386). 

Methods  of  Examination  for  Kidneys  and  Ureters. — The  apparatus 
must  be  good  and  the  tube  one  that  will  differentiate  as  much  as  pos- 
sible between  the  tissues.  The  patient's  bowels  should  be  thoroughly 
emptied,  and  no  meal  should  be  taken  for  some  hours  previous  to 
the  examination.  When  the  patient  has  been  thus  prepared  he  should 
be  placed  flat  on  his  back  on  the  canvas  stretcher,  with  the  plate  sup- 
ported under  the  stretcher,  as  shown  in  Fig.  72.  The  photographic 
plate  used  should  be  sensitive  and  fresh,  and  be  so  placed  as  to  in- 
clude the  last  four  or  five  ribs,  both  kidneys  (as  both  may  contain  cal- 
cuH),  and  the  whole  pelvis,  as  the  calculus  may  be  in  the  ureters.  Two 
or  three  negatives  should  be  taken  for  the  sake  of  greater  certainty. 
Good  negatives  are  those  which  show  the  outline  of  the  soft  tissues, 
such  as  the  kidneys  and  muscles. 

Helen  A.  L.,  twenty-two  years  of  age.  Entered  the  hospital  No- 
vember 5,  1900.     Under  Dr.  Lund's  care.     Diagnosis:  renal  calculi. 

At  the  age  of  ten  she  had  pain  in  the  right  lumbar  region  after  get- 
ting tired.  Five  or  six  years  ago  had  first  attack  of  severe  pain  in  right 
lumbar  region.  Pain  came  on  suddenly.  No  change  noted  in  urine ; 
since  then  three  or  four  similar  attacks.     Has  had  occasionally  a  drag- 

1  "Zur  Diagnose  der  Nephrolithiasis  durch  Roentgenbilder,"  An/i.  f.  /din.  Oiir.,  Berlin, 
1899,  LIX,  pp.  167-174. 


CALCULI 


619 


•  ging  pain  in  the  same  region  while  lying  on  the  left  side.  Last  attack 
j  two  years  ago ;  present  attack  three  weeks  ago. 

;  November  9.  Examination  of  urine  showed  little  trace  of  albumen  ; 
:  considerable  pus  ;  a  few  blood  globules ;  no  crystalline  elements  and  no 
1  positive  evidence  of  chronic  pyelitis. 


i  Fig.  387.     On  the  left  is  seen  the  outhne  of  the  side  of  the  body,  and  about  i  centimetre  from  it 

I  the  outhne  of  the  muscles.     The  group  of  dark  areas  to  the  right  of  the  centre  and  below  the  middle 
I  of  the  cut  indicate  the  calculi.      On  the  negative  they  are  much  more  readily  made  out,  but  it  has  not 
[  been  possible  to  reproduce  them  satisfactorily.     Six  or  seven  stones  were  counted  on  the  negative 
before,  ten  were  found  after  operation  ;  composition,  uric  acid  and  urates  coated  with  calcic  phosphate. 


'  X-ray  examination  on  November  9  showed  stones  in  right  kidney; 
1  six  or  seven  could  be  made  out  on  the  negative.  See  Fig.  387. 
i  November  10.  Operation  done.  Kidney  found  low  down  in  lumbar 
I  region;  cortex  split  along  convex  border  and  a  number  of  stones  rc- 
i  moved  from  calices,  pelvis,  and  infundibula.  As  little  secreting  kidney 
I  remained,  it  was  removed.  The  patient  made  a  good  recovery.  Dis- 
j  charged  December  15.     See  also  Figs.  388  and  389. 


620     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

Comparison  of  X-Ray  Negatives  and  Radiographs.  —  The  negatives 
should  be  carefully  examined,  —  we  must  not  be  satisfied  with  the  appear- 


FlG.  388.     Shows  a  radiograph  of  the  calculi  after  they  had  been  removed  from  the  kidney. 

ances  seen  on  the  radiograph,  —  as  often  the  dry  negative  will  reveal 
clearly  what  the  print  at  most  suggests.  Further,  some  things  may  be 
seen  during  the  development  of  the  plate,  which  are  not  apparent  later. 


Flc,   3;-;y.     Radiograph  mI  tlic  kidney  utter  removal. 

Comparison  of  X-Ray  Negative  and  Fluorescent  Screen.  —  The  fluo- 
rescent screen  is  not  so  satisfactory  as  X-ray  negatives  in  making  exami- 


I  CALCULI  621 

i  nations  for  calculi,  and  should  not  be  employed  for  this  purpose,  for, 
j  unless  the  stones  are  large  and  made  up  of  oxalate  or  phosphate  of  cal- 
I  cium,  they  would  not  be  detected  on  the  fluorescent  screen. 

I        Fenwick's  Method  of  Examination  of   Kidney  outside  the    Body. 

Fcnwicki  j^as  examined  the  kidney  with  the  fluorescent  screen  after  it 
has  been  taken  out  from  the  patient's  loin.  This  procedure,  as  he  states, 
would  not  always  be  possible,  as  in  some  patient's  the  blood  vessels  are 
t(K)  short  to  permit  of  it;  further,  this  method  might  entail  delay,  for  if 
the  surgeon  who  took  out  the  kidney  should  also  make  the  X-ray  ex- 
amination, he  would  be  obliged  to  remain  in  a  darkened  room  for  ten 
minutes  before  he  could  use  the  fluorescent  screen  properly,  as  it  would 
be  entirely  useless  to  give  any  weight  to  the  results  of  an  X-ray  examina- 
t  tion  unless  the  observer's  eyes  were  in  a  proper  condition  for  seeing. 

Method  of  Examination  for  Bladder;   Photograph  taken  outside  of 
!l  Bladder.  —  It  is  desirable  to  so  place  the  patient  when  he  is  examined 
,;  that  the  plate  should  be  as  near  as  possible  to  the  calculus.     He  should 
1  therefore  lie  on  his  face  on  the  stretcher ;  the  tube  should  be  placed 
above  him  and  the  plate  under  him,  as  this  position  would  bring  the 
calculus  nearer  the  plate  than  any  other,  unless  he  is  stout,  or  the  calcu- 
lus is  not  free  in  the  bladder.      In  either  of  these  cases  he  should  lie  on 
his  back  with    the  plate  under  him.     The  operator  cannot  determine 
whether  or  not  the  calculus  is  free  in  the  bladder,  and  therefore  if  the 
patient  is  thin,  and  the  results  are  not  satisfactory  when  the  radiograph 
was  taken  with  the  patient  lying  on  his  face,  a  second  X-ray  photograph 
should  be  taken  when  he  is  lying  on  his  back.     The  size  of  the  calculus 
is  shown  on  the  radiograph,  and  sometimes  its  composition  is  indicated 
by  its  shape,  as  in  the  mulberry  calculus  for  instance. 

The  bladder  is  of  course  more  accessible  to  other  means  of  examina- 
tion than  many  other  parts. 

Instrument  for  Photographing  Calculi  in  the  Bladder. — The  follow- 
ing cut  shows  an  instrument  Rollins  devised  in  1896  for  photograph- 
ing a  calculus  in  the  bladder.  It  consists  of  an  aluminum  tube  22.5 
centimetres  long  and  2.5  centimetres  wide,  which  is  closed  with  a 
soHd  piece  of  metal  at  one  end,  while  to  the  other  is  fitted  a  handle 
which  screws  on  (see  HH,  Fig.  390).  FC  is  a  thin  piece  of  metal  with 
grooved  edges  which  holds  several  photographic  films  or  pieces  of 
bromide  paper  that  should  be  about  as  wide  as  the  tube  and  about  half 
its  length. 

^British  Medical  Journal,  1897,  P-  I075;    International  Medical  Annual,  1898,  p.  H^. 


62  2     THE   ROENTGEN    RAVS   IN    MEDICINE   AND   SURGERY 

Direction  for  its  Use.  —  The  instrument  should  be  got  ready  for  use 
in  a  dark  room.  To  put  the  films  in  place  the  sliding  piece  FS  is 
removed  from  FC,  and  the  films  are  slid  into  the  grooves  and  pushed  to 


Fig.  390.     Instrument  for  photographing  a  calculus  in  the  bladder.     (Rollins.) 

the  end  as  far  as  they  will  go.  FS  is  then  put  back  to  hold  the  films  in 
place,  and  the  tube  is  then  pushed  inside  of  HB,  and  the  round  handle 
Ff  screwed  on. 

The  patient  is  placed  on  his  back  and  the  tube  above  the  bladder ; 
the  instrument  with  the  convex  side  up  is  then  inserted  into  the  rectum 
and  held  in  such  a  position  that  the  films  are  brought  just  below  the 
bladder.  After  a  proper  exposure  the  instrument  is  taken  out  and 
the  films  are  developed.  In  the  two  cases  in  which  I  have  used  this 
instrument  nothing  was  found  on  the  films ;  calculi  were  present, 
however,  and  were  removed,  but  proved  on  analysis  to  be  made  up 
of  uric  acid. 

This  instrument  may  also  be  passed  into  the  vagina  and  a  photograph 
may  then  be  taken  of  the  bladder. 

I  give  below  an  account  of  the  majority  of  cases  thus  far  reported, 
at  this  writing,  in  which  the  recognition  of  calculi  by  the  X-rays  was 
confirmed  by  operation  or  by  autopsy,  because  it  is  instructive  to  note 
the  amount  of  successful  work  done  in  this  direction,  and  the  composi- 
tion of  the  stones  of  which  the  X-rays  have  given  evidence ;  and  I 
desire  at  the  same  time  to  direct  special  attention  to  Dr.  Leonard's  and 
Dr.  Abbe's  articles  on  the  use  of  the  X-rays  in  this  field,  as  they  have 
devoted  themselves  most  zealously  to  this  subject. 


CALCULI 


623 


The  following  case  is  the  first  in  which  the  X-rays  were  successfully 
employed  to  point  out  a  calculus :  — 

Case  L  Dr.  Maclntyre  of  Glasgow  {Lancet,  London,  July  11, 
1896).  Calculus  found  by  X-rays  in  one  patient.  Diagnosis  confirmed 
by  operation. 

Case  IL  Swain  {Bristol  Alcdico-Chirnrgical  Journal,  1897,  p.  i). 
Patient:  male,  twenty-seven  years  old.  Composition  of  calculus: 
oxalate  of  calcium.  Size:  i^x|x|  inches.  Weight:  148  grains. 
Symptoms  :  transient  hasmaturia,  pain.     In  urine,  pus  cells. 

Case  IIL  Gorl  {Miinch.  Med.  Woclicnschr.,  April  5,  1898)  reported 
at  a  meeting  of  a  German  medical  society,  December  2,  1897,  the  find- 
ing of  a  hard  stone  by  the  X-rays,  of  the  size  of  a  plum,  which  was 
removed  by  operation. 

Case  IV.  Thyne  {Austi-alasian  Medical  Gazette,  October  20,  1897, 
p.  502).  Patient :  female.  Composition  of  calculus  :  oxalate  of  lime,  with 
a  coating  of  phosphate  of  lime.  Weight:  275  grains.  Symptoms :  renal 
colic  and  vomiting.     In  urine,  pus. 

Case  V.  Taylor  and  Fripp  (Trans.  CUn.  Soc,  London,  1 897-1 898, 
pp.  200-202)  report  a  case  in  which  a  renal  calculus  was  detected  by  an 
X-ray  photograph  and  successfully  removed.  The  patient  was  a  man 
twenty-six  years  old.  Several  X-ray  photographs  were  taken  without 
detection  of  any  opacity  in  either  loin.  An  incision  was  then  made  to 
explore  the  right  lumbar  region,  but  the  kidney  could  not  be  found. 
Three  days  later  another  X-ray  photograph  was  taken,  in  which  a 
definite  though  not  well-defined  opacity  was  evident.  It  was  thought 
to  be  a  stone,  though  it  was  very  high  up,  above  the  twelfth  rib.  The 
wound  was  reopened,  and  the  stone  was  discovered  and  removed.  The 
calculus  was  made  up  of  alternate  layers  of  uric  acid  and  phosphate, 
weighed  half  an  ounce,  and  was  if  inches  long,  |  inch  wide  and  |  inch 
thick.  Examination  of  the  urine  showed  only  slight  traces  of  blood  on 
three  days  out  of  thirty-eight.  The  fact  that  several  X-ray  photographs 
were  made  before  the  stone  was  detected  is  a  special  point  of  interest  in 
this  case. 

Case  VI.  Bevan  {Chicago  Medical  Recorder,  March,  1898), 
Patient :  male,  thirty  years  old.  Large  stone.  Composition  not 
given. 

Case  VII.  Mc Arthur  {Chicago  Medical  Recorder,  February,  1898) 
reports  the  case  of  a  patient  supposed  to  be  suffering  from  pyelitis,  who 
had   previously   had   a  stone   removed   from   one  kidney.     The  X-rays 


624     'I'HE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

showed  a  stone  in  the  other  kidney,  which  was  removed.  The  stone 
was  phosphatic  and  measured  l  inch  by  .}  inch. 

Case  VIII.  Lauenstein  {^DciitscJic  ZcitscJirift  f.  CJiirurgic,  No.  50, 
1 898- 1 899,  p.  195).  Patient:  male,  forty-seven  years  old.  Composition 
of  calculus,  carbonate  of  calcium,  oxalate  of  calcium,  and  uric  acid. 
Size:  2|xi|.xi  centimetre.  Weight:  8  grammes.  The  shadow  seen 
on  the  plate  was  2  by  3  centimetres,  and  was  3  centimetres  distant  from 
the  border  of  the  twelfth  rib,  4  centimetres  from  the  body  of  the 
vertebrae,  and  8  centimetres  from  the  spinous  processes.  The  evidence 
obtained  by  the  X-rays  enabled  Lauenstein  to  make  an  incision  in  the 
kidney  just  large  enough  to  extract  the  stone,  wdiich  was  of  the  size 
indicated  in  the  radiograph. 

Case  IX.  Dr.  C.  A.  Morton  {Lancet,  London,  1898,  Vol.  I, 
p.  1534)  reports  a  case  of  a  patient  twelve  years  old,  where  the  stone 
was  detected  in  the  kidney  by  means  of  an  X-ray  photograph  after 
the  subsidence  of  all  symptoms.  He  had  had,  during  previous  attacks, 
severe  pain  in  the  left  loin,  frequent  passage  of  urine,  and  hasmaturia. 
When  admitted  to  the  hospital  there  was  no  sensitiveness  to  pressure 
over  the  kidney.  The  bladder  was  sounded  with  negative  result.  Pain 
in  the  left  loin  ;  vomiting,  but  no  hasmaturia ;  muscles  over  the  kidney 
became  rigid  during  attacks  of  pain.  He  apparently  recovered,  so  that 
he  could  run  and  jump  without  pain.  The  only  distress  w^as  along  the 
urethra  after  micturition.  An  X-ray  photograph  showed  a  shadow  over 
the  twelfth  rib,  and  operation  discovered  a  typical  oxalate  of  calcium 
stone,  which  was  J  x  |  inch  in  size.     The   patient  recovered. 

Case  X.  Dr.  Herman  {Wien.  klin.  IVochcnsc/ir.,  1899,  Vol.  VIII, 
p.  190)  cites  a  patient  thirty-nine  years  old,  in  whom  clinical  examina- 
tion showed  all  the  symptoms  of  a  stone  in  the  bladder,  but  its  existence 
could  not  be  corroborated  by  an  instrument.  X-ray  examination  showed 
repeatedly  the  existence  of  two  stones,  one  the  size  of  a  walnut  and  the 
other  the  size  of  a  hazelnut.     They  were  removed  by  operation. 

Case  XI.  Dr.  Herman  also  reports  the  following  case  (  Wicn.  klin. 
Woc/icnschr.,  1899,  Vol.  VIII,  p.  190):  A  patient  twenty-six  years  old, 
from  whom  a  stone  the  size  of  a  hazelnut  was  removed,  was  examined  by 
the  X-rays  because  the  wound  showed  no  tendency  to  heal  after  several 
weeks.  The  Roentgen  picture  showed,  about  10  centimetres  to  the  left 
of  the  spinal  column,  three  indistinct  shadows ;  the  largest  the  size  of  a 
pea,  the  smallest  the  size  of  a  lentil.  The  large  shadow  of  the  kidney 
lay  outward  from  the  shadows  of  the  stones.     After  the  removal  of  the 


CALCULI 


625 


stones  the  correctness  of  the  size  of  the  shadows  noted  in  the  radiograph 
was  corroborated  by  the  stones. 

Case  XIL  Alsberg  (Munch.  Med.  Wochenschr.,  December  20,  1898) 
reports  the  case  of  a  man  thirty-four  years  old ;  a  shipbuilder,  large, 
powerful,  and  well-nourished,  who  entered  the  hospital  in  June,  1898. 
He  had  suffered  for  ten  years  with  pain  in  the  right  side,  below  the 
arch  of  the  ribs.  He  attributed  this  to  a  blow  from  a  mast.  In  1893 
he  went  to  the  hospital.  Nothing  unusual  was  found  and  massage  was 
without  effect.  He  left  the  hospital  after  several  weeks,  unrelieved. 
After  this  he  had  constant  pain,  and  finally  was  obliged  to  walk  in  a 
bent  position.  Another  physical  examination  showed  nothing  except 
tenderness  over  the  right  kidney.  The  urine  was  clear  and  without 
albumen,  and  the  microscopic  examination  negative. 

A  Roentgen  photograph  showed,  about  4  centimetres  to  the  right  of 
the  spinal  column,  a  sharply  defined  uniform  shadow.  This  shadow 
was  3 1  centimetres  long  and  2\  centimetres  broad.  \\  centimetres 
below  and  outward  from  this  shadow  was  seen  a  second,  i  centimetre 
in  diameter,  round,  but  with  indefinite  borders.  An  operation  found 
the  stones  just  as  shown  in  the  Roentgen  picture,  the  smaller  one  being 
made  up  of  little  stones  about  the  size  of  peas.  The  large  stone  was 
very  hard,  dark  brown  in  color,  \  centimetre  thick,  and  made  up  of  oxa- 
late of  calcium.  It  weighed  8  grammes.  The  smaller  stones  together 
weighed  2  grammes  and  were  made  up  of  oxalates.  In  this  case  it  was 
possible  to  make  a  certain  diagnosis  by  means  of  the  X-rays,  and  the 
carrying  out  of  the  operation  was  made  easy,  as  the  stones  were  so 
accurately  located  that  it  was  not  necessary  to  search  for  them. 

Cases  XIII,  XIV,  XV,  and  XVI.  Mackenzie  Davidson  {Archives 
of  the  Roentgen  Ray,  May,  1899)  reports  four  cases  in  which  a  diag- 
nosis of  renal  calculi  was  made  by  the  X-rays  and  confirmed  by  opera- 
tion. One  case  was  that  of  a  boy  eighteen  years  old.  The  stone  was 
made  up  of  uric  acid  with  a  thin  crust  of  oxalate  of  calcium  ;  size :  2  x 
\^-^  inches. 

Cases  XVII  and  XVIII.  V^^ignQV {Centra Ihhrtt  f.  Chirurgie,  No.  8, 
1899)  reports  two  cases.  First  case  that  of  a  girl  ten  years  old.  Radio- 
graph showed  four  stones,  one  large  and  three  small.  They  were  made 
\  up  of  phosphate  of  potassium  and  magnesium,  with  a  trace  of  ammonium 
I  phosphate.  The  second  case  was  that  of  a  woman  thirty-eight  years  old. 
!  A  stone  the  size  of  a  walnut  was  discovered  in  the  pelvis  of  the  kidney. 
I  This  was  verified  by  autopsy. 


626     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

Case  XIX.  McBurney  of  New  York  reported  at  a  meeting  of  the 
Practitioners'  Association,  in  1898,  the  successful  removal  of  a  calculus 
I  inch  in  diameter,  which  had  been  found  by  means  of  the  X-rays. 

Case  XX.  Longard  {Deutsche  Med.  WochenscJir.,  No.  4,  1898) 
reports  a  case  in  which  his  X-ray  photograph  showed  that  there  were 
four  stones  in  the  bladder,  and  this  diagnosis  was  confirmed  by  opera- 
tion. The  X-ray  photograph  also  showed  the  presence  of  a  fifth  stone 
which  was  not  found  in  the  bladder,  but  in  the  ureter  behind  the  bladder, 
at  a  second  operation. 

Case  XXI.  G.  Julliard  {Fortsc/iritte  a.  d.  Gebietc  d.  RoentgenstraJi- 
len,  B.  II).  Patient :  male,  thirty-four  years  of  age.  The  presence  of  a 
calculus  was  demonstrated  by  the  metallic  sound.  An  X-ray  photo- 
graph was  afterward  made  which  gave  a  very  clear  shadow  of  the  cal- 
culus, its  place,  its  shape,  and  its  size.  After  operation  the  stone  was 
measured.  Its  length  was  25  millimetres,  and  its  greatest  width  15  milli- 
metres. It  weighed  4  grammes.  It  was  made  up  of  calcic  oxalate  and 
a  trace  of  ammonium  magnesium  phosphate. 

Cases  XXII  and  XXIII.  Abbe  of  New  York  {Annals  of  Surgery, 
August,  1899)  reports  two  cases.  The  first  was  that  of  a  man  twenty- 
seven  years  old.  Composition  of  calculus,  oxalate  of  calcium  and 
urates.  Size :  -|  inch  in  diameter.  Symptoms :  haematuria  and  pain. 
The  second  case  was  that  of  a  woman  twenty-eight  years  old.  Compo- 
sition of  calculus,  oxalate  of  lime.  Size :  |  inch  in  its  longest  measure- 
ment. Symptoms :  renal  colic.  The  shadow  was  seen  between  the 
eleventh  and  twelfth  ribs  i  \  inches  from  the  vertebral  edge. 

Cases  XXIV,  XXV,  and  XXVI.  Albarran  {Annales  des  Maladies 
des  Organes  Genito-Urinaires,  pp.  673-687,  1899).  Patient:  a  man  twenty- 
eight  years  of  age.  By  process  of  elimination  Albarran  arrived  at  the 
conclusion  that  the  patient  had  renal  calculi.  An  X-ray  photograph 
was  then  taken  which  showed  on  the  left  side,  9  centimetres  from  the 
median  line,  a  very  clear  shadow  which  was  partially  hidden  by  the 
eleventh  rib.  It  was  of  irregular  form  and  resembled  a  reversed  "  L." 
Its  greatest  length  and  breadth  was  5  centimetres.  On  the  right  side 
were  three  small  shadows,  the  largest  of  which  was  not  as  big  as  a  nut. 
The  first  was  below  the  eleventh  rib ;  the  second  between  the  eleventh  and 
twelfth  ribs ;  and  the  third  below  the  twelfth  rib,  near  its  end.  The  opera- 
tion on  the  left  side  confirmed  the  diagnosis  made  by  the  X-ray  photo- 
graph. Albarran  also  cites  the  two  following  cases  reported  by  Miiller 
and  Braatz  :  — 


CALCULI 


627 


Midler.  —  The  radiograph  gave  positive  information  which  was  con- 
firmed by  operation.  The  calculus  was  made  up  of  carbonate  of  lime 
with  traces  of  uric  and  oxahc  acid. 

Braatz.  —  The  radiograph  gave  a  clear  picture  of  a  renal  calculus 
which  was  confirmed  by  operation.    The  stone  was  oxahc  in  composition. 

Case  XXVII.  Rutherford  Morrison  {British  Medical  Journal, 
November  18,  1899).  Calculus  removed  by  operation  owing  to  the 
evidence  obtained  from  the  patient's  symptoms  and  the  X-rays.  The 
stone  was  the  size  of  a  filbert  and  was  made  up  of  oxalate  of  lime. 

In  the  Annals  of  Surgery,  August,  1899,  Dr.  Leonard,  who  has  had 
the  largest  experience  in  this  field,  gives  fifty-nine  cases  which  he  had 
personally  examined  by  the  X-rays,  and  in  eight  of  the.se  the  evidence 
obtained  by  the  X-rays  was  confirmed  by  operation.  I  quote  below  these 
latter  eight  cases  :  — 

"Case  i.  —  March  15,  1898.  Mr.  C.  S.  W.,  referred  by  Dr.  Edward 
Martin.  His  symptoms  were  sufficiently  pronounced  to  lead  to- a  diag- 
nosis of  calculus.  This  diagnosis  was  confirmed  by  the  skiagraph,  with 
the  additional  detail  that  two  calculi  were  present,  and  giving  their  posi- 
tion. This  facilitated  their  removal,  as  the  smaller  calculus  was  encysted, 
and  was  only  found  by  measurements  derived  from  the  skiagraph. 
They  were  uric  acid  calculi,  weighing  32  grains  and  10  grains. 

"  Case  6.  —  May  17,  1898.  Mr.  H.  A.  L.,  referred  by  Dr.  J.  William 
White.  Had  had  attacks  of  renal  colic  at  frequent  intervals,  and  had 
passed  previously  a  small  mulberry  calculus.  Two  months  ago  the  pas- 
sage of  gravel  ceased,  and  the  paroxysms  of  pain  increased  in  frequency 
and  intensity.  Urine  was  acid;  sp.  gr.  1032.  No  blood,  no  pus,  heavy 
deposits  of  uric  acid  gravel.  The  skiagraph  showed  the  presence  of  a 
calculus,  which  was  found  encysted  in  the  superior  calyx,  and  was  cov- 
ered with  urates.     It  weighed  21  grains. 

"  Case  8.  —  Mrs.  A.  D.  K.,  referred  by  Dr.  J.  William  White.  In  this 
patient  calculi  were  present  in  both  kidneys.  The  right  kidney  was 
operated  upon  and  the  calculus  removed.  The  patient  recovered  from 
the  operation,  but  the  kidney  was  too  nearly  disorganized  to  maintain 
its  function.  The  post-mortem  examination  showed  the  skiagraphic 
diagnosis  to  be  correct,  and  that  the  three  calculi  in  the  left  kidney  had 
destroyed  it  totally,  although  no  symptoms  had  ever  been  referred  to  that 
side  or  that  kidney.    The  calculus  removed  weighed  4  drachms  10  grains. 

"Case  ii.  — November  19,  1898.  Mr.  C.  S.,  referred  by  Drs. 
Mitchell  and  Martin.    This  patient  had  had  marked  but  indefinite  symp- 


628     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

toms  of  renal  calculus,  extending  over  a  period  of  twelve  years.  Al- 
though examined  on  numerous  occasions  by  prominent  surgeons,  the 
diagnosis  had  never  been  established,  while  exploratory  nephrotomy  had 
only  been  once  suggested.  The  symptoms  at  this  time  were  more 
marked  but  were  still  indefinite.  The  skiagraph  showed  a  large  hydro- 
nephrotic  kidney,  with  one  large  and  two  small  calculi.  Every  detail 
was  subsequently  confirmed  by  the  operation.  The  kidney  was  saccu- 
lated and  enlarged,  and  the  three  calculi  were  removed.  The  patient 
recovered  completely.  In  this  case,  as  in  others  where  multiple  calculi 
were  shown,  the  value  of  such  detail  was  demonstrated  in  making  the 
operation  complete. 

"Case  12.  —  November  29,  1898.  Mr.  J.  H.,  referred  by  Dr.  James 
Tyson.  He  has  had  indefinite  lumbar  pain  for  six  years  ;  has  had  slight 
traces  of  blood  in  urine,  but  had  never  passed  a  calculus.  The  only 
symptoms  were  lumbar  pain,  a  trace  of  pus,  and  some  albumen.  The 
skiagraphs  showed  a  small  calculus.  Dr.  White  performed  an  explora- 
tory nephrotomy,  but  was  unable  to  palpate  the  calculus  or  touch  it  with 
a  needle  in  the  apparently  healthy  kidney.  The  incision  into  the  kidney 
disclosed  the  correctness  of  the  diagnosis,  as  an  oxalate  calculus  was 
removed  that  weighed  twelve  grains. 

"Case  17.  —  December  6,  1898.  Mr.  W.  W.,  referred  by  Dr.  J. 
William  White.  He  had  had  frequent  attacks  of  acute  pain  in  the  lum- 
bar region,  but  not  characteristic  of  renal  colic.  Just  before  the  exami- 
nation he  had  had  pain  with  chill  and  sweating,  with  a  lingering  pain 
through  back  and  limbs.  The  urine  was  normal  in  odor  and  color,  no 
albumen,  no  sugar,  acid  in  reaction  ;  the  microscope  showed  a  few  pus- 
cells,  occasional  red  cells,  some  epithelium,  but  no  casts.  The.  skiagraph 
showed  the  presence  of  a  calculus,  which  was  removed  by  operation 
and  weighed  17  grains.     It  was  composed  of  phosphates  and  oxalates. 

"  Case  24.  —  March  7,  1899.  Mr.  A.  D.  C,  referred  by  Dr.  W.  W. 
Keen.  The  patient's  symptoms  were  sufficiently  typical  to  make  the 
diagnosis  of  calculous  disease  probable.  The  skiagraphs  made  it  posi- 
tive. The  oxalic  acid  calculus  was  subsequently  removed  and  weighed 
48  grains. 

"Case  53.  —  October  24,  1899.  J.  J.  M.,  referred  by  Dr.  A.  J. 
Downes.  This  patient  had  passed  calculi  on  three  occasions.  The 
last  was  passed  five  years  ago,  since  which  time  he  had  been  free  from 
symptoms  until  nine  months  ago,  when  an  absce.ss  formed  in  the 
lumbar  region  and  was  opened.     The  patient  was,  however,  so  weak 


CALCULI 


629 


that  a  more  serious  operation  was  not  advisable.  The  sinus  was 
reopened  three  months  ago,  but  the  physical  condition  still  contra- 
indicated  extensive  exploration.  The  urine  has  contained  a  slight 
trace  of  pus  from  time  to  time  and  some  red  blood  corpuscles.  The 
skiagraph  showed  a  large  calculus  in  the  left  lumbar  region  opposite 
the  inter-vertebral  cartilage  of  the  second  and  third  lumbar  vertebrse. 
At  the  subsequent  nephrolithotomy  it  was  found  that  the  shadow  of 
the  calculus  had  been  cast  by  a  mass  of  amorphous  urates  and  phos- 
phates contained  in  a  crystalline  shell  that  filled  the  pelvis  of  the  kid- 
ney. This  mass  broke  up  readily  under  the  finger,  and  contained 
minute  uric  acid  calcuH.  The  detection  of  a  calculus  of  such  character 
leaves  no  doubt  of  the  accuracy  and  efficiency  of  this  method,  and  its 
value  in  negative  diagnosis." 

So  far  as  I  have  been  able  to  gather  from  the  literature  accessible 
to  me,  of  cases  published  at  the  time  these  were  collected,  there  have 
been  thirty-five  cases  where  a  diagnosis  of  the  presence  of  renal  calculi 
by  means  of  a  radiograph  was  confirmed  by  operation.  In  fourteen 
cases  the  composition  was  not  given.  In  all  the  others  they  were  either 
made  up  in  part  or  in  whole  of  oxalate  or  phosphate  of  calcium,  except  one 
of  Dr.  Leonard's,  in  which  there  were  calculi  of  uric  acid  weighing  10  and 
32  grains  respectively ;  and  the  case  on  pages  617,  619,  620,  in  which  the 
calculi  were  made  up  of  uric  acid  and  urates  coated  with  calcic  phosphate. 

In  the  present  stage  of  this  study,  it  is  probable  that  a  larger  pro- 
portion of  successful  cases  would  have  been  reported  than  of  unsuc- 
cessful ones,  and  it  is  also  probable  that  out  of  the  considerable  number 
of  unsuccessful  cases  which  had  symptoms  of  a  calculus,  some  of  them 
may  have  been  made  up  of  uric  acid,  and  were  not  recognized  by  the 
X-ray  examination.  When  we  consider  that  in  most  countries  the  uric 
acid  calculi  are  the  most  common  of  all,  and  that  out  of  the  twenty-one 
cases  given  where  the  composition  is  stated,  only  one  is  put  down  as 
pure  uric  acid,  it  would  seem  probable  that  either  the  method  is  not  yet 
carried  out  by  most  observers  as  carefully  as  it  will  be  in  the  future, 
when  it  has  been  perfected,  or  that  pure  uric  acid  calculi  will  always 
remain,  on  account  of  their  having  about  the  same  power  of  absorption 
of  the  X-rays  as  the  soft  tissues  of  the  body,  the  most  difficult  to 
detect,  to  say  the  least. 

It  is  to  be  remembered,  of  course,  that  in  a  considerable  proportion 
of  these  cases  the  diagnosis  was  probable  without  the  X-ray  examination. 


630     THE    ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

Various  authors  have  reported  the  removal  of  renal  calculi  by  opera- 
tion after  failures  to  find  them  by  X-ray  photograph. 

Gall  Stones.  —  Gall  stones  cannot  be  easily  recognized  as  yet  by  the 
X-rays,  because  they  are  generally  composed  of  organic  matter,  and 
therefore  do  not  cast  much,  if  any  more,  shadow  than  the  surrounding 
soft  parts ;  but  if  they  should  contain  salts  of  calcium,  they  would  be 
more  easily  detected.  The  fact  that  the  plate  can  be  brought  near  the 
gall  bladder  is  an  advantage,  and  enables  the  observer  to  obtain  a  better 
photograph  than  when  the  plate  is  at  a  distance.  Some  observers  have, 
however,  reported  a  few  cases  where  they  were  satisfied  that  they  had 
recognized  gall  stones  in  X-ray  photographs,  and  their  diagnosis  was 
confirmed  by  operation. 

Dr.  Carl  Beck  {New  York  Medical  Journal,  January  20,  1900)  has 
made  ninety-seven  radiographs  of  twenty-eight  cases  of  suspected  chole- 
lithiasis, in  nineteen  of  which  the  presence  of  bihary  calculi  was  ascer- 
tained by  operation.  In  only  two  of  these  nineteen  cases  was  he  able 
to  obtain  shadows  on  the  plates,  and  they  were  so  slight  that  he  would 
not  have  relied  upon  them  for  diagnosis.  In  several  of  the  cases  exam- 
ined, he  made  from  six  to  ten  exposures,  varying  the  position  of  the 
plate  and  the  length  of  the  exposure. 

Dr.  Beck's  study  of  this  difficult  problem  has  recently  resulted  in  un- 
usual success,  and  at  a  meeting  of  the  Academy  of  Medicine  of  New  York 
held  in  January,  1901,  he  showed  good  radiographs  of  gall  stones. 

Dr.  Leonard,  in  an  excellent  paper  read  at  the  same  meeting,  stated 
that  about  one-half  of  the  calculi  are  found  in  the  ureters  and  the 
other  half  in  the  kidneys,  exclusive  of  those  found  in  the  bladder  and 
gall  bladder. 

Absence  of  Calculus  not  definitely  determined  by  the  X-Rays.  —  In 
many  cases  where  the  symptoms  point  to  a  diagnosis  of  a  calculus,  but 
it  is  a  question  whether  or  not  one  is  present,  I  think  its  absence  would 
not  be  definitely  demonstrated  by  lack  of  evidence  of  it  in  the  X-ray 
photograph. 

Determination  of  Presence  of  Calculus.  —  On  the  other  hand,  if  evi- 
dence is  obtained  by  at  least  two  X-ray  negatives  of  the  presence  of  a 
calculus,  whether  in  the  kidneys,  ureter,  or  bladder,  even  though  the 
ordinary  indications  are  indefinite,  this  evidence  is  conclusive  ;  the  pres- 
ence and  position  of  the  stones  can  be  accurately  demonstrated. 

Conclusions. — The  presence  of  calculi  containing  inorganic  matter, 
such  as  mineral  salts,  may  be  detected  by  X-ray  photographs.     If  the 


CALCULI  .  5 


o 


apparatus  and  technique  are  very  good,  Dr.  Leonard's  experience  is  that 
calculi  made  up  of  pure  uric  acid  can  also  be  found.  The  X-ray  exami- 
nations give  definite  and  positive  information  as  to  the  location,  and, 
within  certain  Hmits,  as  to  the  number  and  the  size  of  the  calculi.  They 
show  in  which  organ  the  stone  is  present ;  which  kidney  or  which  ureter 
is  affected ;  and  often  whether  there  is  one  stone  or  several.  The 
operation  is  therefore  simplified,  and  the  surgeon  is  less  likely  to  over- 
look a  given  calculus  when  several  are  present.  The  presence  of  cal- 
culi may  be  detected  early  by  means  of  the  X-rays,  also  when  they 
have  been  quiescent  for  some  time  and  give  rise  to  only  slight  or  indefi- 
nite symptoms.  Further,  there  is  no  danger  attending  this  method  of 
examination,  and  no  discomfort. 

Calculi  can  be  more  easily  detected  in  young  or  thin  patients  than  in 
stout  or  adult  persons.  Thickness  is  one  of  the  obstructions  offered  to 
the  passage  of  the  rays,  as  we  have  seen  in  Chapter  I,  and  in  youth  the 
soft  tissues  seem  to  be  more  permeable  by  the  rays  than  in  adult  life. 
But  the  composition  of  the  calculus  has  more  influence  than  the  size  or 
age  of  the  patient.  That  is  to  say,  a  calculus  made  up  of  oxalate  of 
calcium  would  be  far  more  easily  detected  in  a  stout  person  than  a  cal- 
culus of  urates  in  a  thin  patient. 

New  Method  of  Diagnosis. — The  X-rays  then  contribute  one  more 
means  of  diagnosis,  and  in  cases  where  a  calculus  is  suspected  in  the 
urinary  tract,  an  X-ray  examination  should  be  made. 

Difficulty  of  Diagnosis  of  Calculus  by  Ordinary  Methods.  —  It  is 
well  recognized  that  there  are  many  difficulties  in  the  way  of  a  definite 
diagnosis  of  calculi  in  the  urinary  tract.  For  example,  there  are 
various  symptoms  which  suggest  strongly  the  presence  of  renal  cal- 
culi ;  on  the  other  hand,  there  are  cases  of  renal  calculus  which  are 
unsuspected  because  the  symptoms  observed  may  be  referred  to  another 
cause. 

Direct  and  Indirect  Use  of  X-Rays.  —  X-ray  photographs  will  not 
only  be  a  means  of  pointing  out  calculi  directly,  as  indicated,  but  even- 
tually will  also  prove  of  service  by  pointing  them  out  indirectly,  for 
th^y  will  instruct  the  profession  more  exactly  in  regard  to  the  symp- 
toms which  calculi  produce.  That  is  to  say,  the  X-rays,  by  giving 
more  definite  information  than  hitherto  of  a  calculus  in  the  kidney,  for 
example,  will  enable  the  physician  to  associate  characteristic  groups 
of  symptoms  with  its  presence,  that  he  is  not  now  able  to  connect 
definitely  with  the  disease.     In  this  way  the  X-rays  will  increase  the 


632     THE   ROENTGEN    RAYS   IN    MEDICINE   AND   SURGERY 

possibility  of  making  a  tentative  diagnosis  without  an  X-ray  exami- 
nation, and  more  cases  will  be  recognized.  The  X-ray  examination 
would  then  follow  for  more  definite  information. 

The  work  done  by  surgeons  in  this  field  is  a  triumph  of  careful  and 
persistent  endeavor  over  many  obstacles,  and  those  who  have  demon- 
strated the  possibilities  of  the  X-rays  in  this  direction  deserve  the  appre- 
ciation and  gratitude  of  the  profession. 


CHAPTER   XXV 

USEFULNESS    OF    X-RAY    EXAMINATIONS    TO  LIFE  INSURANCE    COM- 
PANIES.    MEDICO-LEGAL  USES  OF  THE  X-RAYS 

The  foregoing  pages  show  the  usefulness  of  these  examinations  in 
life  insurance  cases,  but  it  may  be  of  service  to  call  attention  to  one  or 
two  points  already  discussed. 

The  organs  to  be  considered  by  life  insurance  examiners  in  the  phys- 
ical examination  of  candidates  are  chiefly  the  kidneys,  the  lungs,  and 
the  heart.  Two  of  these  organs  —  the  lungs  and  the  heart  —  are  espe- 
cially open  to  inspection  by  the  X-rays,  and  if  it  is  desirable  to  put  the 
candidate  to  the  least  possible  trouble  he  can  be  thus  examined  with- 
out removing  the  clothing.  In  the  lungs,  for  instance,  old  foci  of 
tuberculosis  give  rise  to  abnormal  appearances,  which  can  be  seen  on 
the  iluorescent  screen,  and  yet  which  might  be  overlooked  by  ausculta- 
tion and  percussion,  if  not  near  the  surface  of  these  organs.  It  is 
important  for  the  insurance  company  to  know  if  such  foci  exist,  because 
they  are  a  source  of  danger.  Emphysema  of  the  lungs  is  best  recog- 
nized by  the  X-rays ;  the  effects  of  old  pleuritic  adhesions  may  some- 
times be  seen  by  this  new  method  of  examination,  and  thoracic  aneu- 
risms may  be  detected  in  an  early  stage. 

The  size  and  position  of  the  heart  can  be  determined  with  greater 
certainty  and  exactness  by  the  X-rays  than  by  the  older  methods.  Some 
companies  will  now  accept  as  risks  persons  who  have  certain  heart  mur- 
murs, but  no  company  would  knowingly  accept  a  man  who  had  an 
enlarged  heart,  and  if  this  organ  is  enlarged  as  the  result,  for  example, 
of  a  valvular  lesion,  or  of  arterio-sclerosis,  renal  disease,  or  a  fatty  mus- 
cle, the  X-ray  examination  not  only  shows  it,  but  shows  it  with  certamty 
and  precision. 

There  is,  I  think,  no  single  method  of  physical  examination  of  the 
thorax  that  gives  more  trustworthy  and  complete  evidence  of  the  nor- 
mal or  abnormal  condition  of  the  organs  in  this  part  of  the  body  than  an 
examination  with    the    fluorescent   screen,  when   properly  carried  out. 

633 


634     THE  ROENTGEN   RAYS  IN   MEDICINE  AND   SURGERY 

From  the  standpoint  of  the  hfe  insurance  company  it  is  not  always 
so  much  a  question  of  what  the  disease  is  as  whether  there  is  or  is 
not  an  abnormal  condition  in  the  chest.  This  method  of  examination 
should  of  course  always  be  made  by  a  physician  who  is  experienced  in 
its  use. 

Medico-Legal  Uses  of  Radiographs.  —  There  is,  I  think,  no  question 
that  radiographs  will  eventually  be  admitted  as  evidence  by  the  courts, 
and  that  they  can  make  some  doubtful  points  perfectly  clear.  Obvi- 
ously, evil  results  Avould  be  produced  if  this  kind  of  evidence  were 
employed  in  any  other  than  an  intelligent  way.  Before  the  radiograph 
is  admitted,  it  should  be  shown  that  it  has  been  taken  by  a  person 
trained  to  this  kind  of  work.  The  position  of  the  part,  of  the  plate, 
and  of  the  tube  should  be  accurately  determined  and  stated.  (See 
Chapter  III,  especially  pages  64  to  66  and  86-87.)  The  point  on  the 
plate  opposite  which  the  tube  was  placed  should  be  indicated  on  the 
radiograph  by  a  metal  letter,  as  shown  on  page  521. 

In  cases  of  fracture,  for  example,  two  views  should  be  taken,  for  the 
reason  given  in  a  preceding  chapter  (page  469).  The  kind  of  fracture 
shown  in  the  radiograph  might  give  some  indication  of  the  force  which 
caused  it,  and  this  knowledge  might  sometime  be  useful  from  a  medico- 
legal standpoint.  For  instance,  there  would  be  a  difference  of  character 
in  the  fracture  produced  by  a  direct  and  heavy  blow,  as  from  the  kick  of  a 
horse,  and  in  that  produced  by  torsion.     (See  Figs.  291  and  292.) 

In  fractures  it  is  of  the  first  importance  to  distinguish  between  the 
functional  and  the  anatomical  results.  It  is  already  recognized  that  a 
perfectly  useful  limb  may  not  look  well  in  the  radiograph,  and  as  it  is 
the  desire  of  both  the  surgeon  and  the  patient  to  have  as  serviceable  a 
member  as  possible,  this  test  rather  than  the  anatomical  one,  as  shown 
by  the  radiograph,  should  be  followed.  No  covering,  other  than  a 
sheet,  should  be  allowed  over  the  part  of  which  a  radiograph  is  to  be 
taken,  especially  if  it  is  a  question  of  a  foreign  body,  as  there  might  be 
objects  opaque  to  the  rays  in  the  clothing. 

Radiographs  should  be  read  not  only  by  a  surgeon,  but  by  a  surgeon 
who  is  trained  in  reading  them.  In  cases  of  poisoning  we  do  not  expect 
the  jury  to  interpret  all  the  tests  which  the  chemist  has  made,  but  the 
latter  can  make  the  meaning  of  these  tests  clear  to  the  jury. 


APPENDIX 

As  more  and  more  hospitals  will  have  an  X-ray  department,  a  few  words  in 
regard  to  the  development  of  the  one  at  the  Boston  City  Hospital  may  be  of 
service.  In  1896  the  Trustees,  who  have  shown  much  interest  in  this  method  of 
examination,  kindly  placed  a  room  at  my  disposal,  in  which  I  set  up  my  apparatus 
and  made  examinations  with  the  fluorescent  screen  and  by  means  of  radiographs 
for  more  than  two  years,  and  in  which  I  have  also  taught  something  of  this  method 
of  examination  to  students  in  connection  with  exercises  in  clinical  medicine. 

In  189S  Mr.  Ernest  Fewkes  was  appointed  to  do  the  radiographic  and  photo- 
graphic work  of  the  hospital.  Mr.  Fewkes  had  no  knowledge  of  X-ray  work  when 
he  was  appointed,  but  his  twelve  years'  experience  as  a  photographer  and  his 
marked  mechanical  ability  were  strong  recommendations.  I  taught  him  how  to 
use  the  apparatus  and  to  take  radiographs,  and  gave  much  time  to  this  part  of  the 
work  for  more  than  another  year,  and  still  supervise  it.  The  X-ray  photographs 
which  have  been  reproduced  in  the  preceding  pages  were  made  for  the  most  part 
by  Mr.  Fewkes.  The  medical  work  with  the  fluorescent  screen  I  have  thus  far 
done  myself,  and  any  physician  whose  interest  lies  in  diseases  of  the  chest  will 
find  it  advantageous  to  learn  how  to  use  it,  just  as  the  laryngologist  has  found  it 
necessary  to  learn  to  use  the  laryngoscope,  and  the  ophthalmologist  the  ophthal- 
moscope. 

At  the  Boston  City  Hospital  three  different  requisition  blanks  are  used,  —  one 
when  a  radiograph  is  desired,  another  when  it  is  desired  to  make  an  examination 
with  the  fluorescent  screen,  and  still  a  third  when  an  ordinary  photograph  is 
wanted.  These  are  filled  out  by  the  house  officer  and  signed  by  the  visiting  phy- 
sician or  surgeon.  These  blanks  are  then  sent  to  Mr.  Fewkes,  and  an  appointment 
is  made  for  the  patient  to  go  to  the  X-ray  room.  The  blank  gives  the  name 
of  the  patient,  the  ward  and  bed  number ;  also  the  volume  and  page  of  the 
medical  or  surgical  record.  The  negatives  are  seen  by  the  surgeon,  or  the  physi- 
cian, as  the  case  may  be,  and  a  print  of  each  is  inserted  in  the  record  book  as  a 
part  of  the  record  of  the  patient.  When  an  examination  with  the  fluorescent 
screen  has  been  made,  a  memorandum  of  it,  and  a  tracing  if  desired,  is  mserted 
in  the  record  book. 

A  portable  apparatus  might  be  used  at  the  bedside,  but  where  the  method  of 
examination  employed  at  the  Boston  City  Hospital  is  followed,  there  are  few 
patients  who  cannot  easily  be  taken  to  the  X-ray  room  on  a  stretcher,  exammed 
upon  it,  and  then  be  brought  back  to  their  beds.     (See  page  27.) 

■  6.:;:; 


636     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

The  time  has  come  when  every  large  hospital  should  make  proper  provision 
for  X-ray  work  ;  by  this  I  mean  provide  opportunity  for  having  X-ray  photographs 
taken  for  the  surgical  side  of  the  hospital,  and  for  the  making  of  fluoroscopic  exami- 
nations and  for  the  therapeutic  uses  of  the  X-rays.  These  needs  demand  more 
than  one  X-ray  apparatus  ;  and  suitable  rooms,  including  a  developing  room  and 
dressing  and  waiting  rooms  for  the  patients. 


X-RAY    EQUIPMENT 

The  question  of  the  best  form  of  X-ray  apparatus  is  still  an  unsettled  one,  the 
ideal  apparatus  is  yet  to  be  devised.  During  the  past  seven  years  I  have  had 
seven  static  machines,  each  better  than  its  predecessor,  and  five  coils,  each  one 
successively  larger  than  the  other.  I  have  likewise  had  the  temporary  use  of  still 
other  apparatus  from  different  manufacturers,  and  I  have  also  talked  with  many 
medical  men  from  other  parts  of  the  country  when  they  were  visiting  the  X-ray 
room  at  the  Boston  City  Hospital,  or  at  my  office,  and  have  learned  from  them 
what  they  have  seen  in  other  places,  as  well  as  profited  by  my  own  visits  to 
others.  The  result  of  these  inquiries  and  of  my  own  experience  may  be  in  part 
summed  up  as  follows  :  — 

Generator.  —  The  requisites  for  the  best  work  are  a  generator  of  abundant 
power,  provided  with  adjustable  multiple  spark-gaps  (see  pages  16  and  17)  and 
good  tubes  with  regulators.  If  the  generator  is  wanting  in  power,  it  will  not  be 
able  to  excite  a  tube  of  high  resistance ;  and  although  it  can  excite  one  of  low 
resistance,  the  amount  of  light  generated  will  not  be  great,  therefore  the  need  of 
a  powerful  generator  is  evident.  With  it  an  efficient  amount  of  light  can  be 
obtained,  and  by  suitably  adjusting  the  regulator  of  a  well-made  self-regulating 
tube  the  desired  quahty  can  be  produced. 

Static  Machine.  —  Moisture  is  the  great  drawback  of  the  static  machine;  an 
efficient  one  is  more  expensive  than  a  coil,  and  photograp)hic  plates  need  a  longer 
exposure  than  when  a  very  large  coil  is  used ;  but  it  gives  a  steadier  light  than  a 
coil,  and  therefore  is  excellent  for  fluoroscopic  work ;  tubes  ranging  over  wider 
limits  of  resistance  can  be  used  on  it  and  they  last  longer;  it  is  independent  of 
an  electric  main. 

A  rather  longer  time  is  necessary  as  stated  above  to  take  a  radiograph  when 
a  static  machine  is  used  than  when  a  large  coil  is  employed,  but  this  is  not  a 
serious  matter,  since  if  a  patient  is  placed  in  a  comfortable  position  he  can  with- 
out inconvenience  retain  it  sufficiently  long. 

The  time  required  to  take  a  radiograph  of  a  child  is  shorter  than  that  for  an 
adult ;  but  if  a  very  rapid  exposure  is  necessary  in  the  case  of  a  child,  the  tube  may 
be  placed  a  little  nearer  than  usual.  If  instantaneous  radiographs  of  the  chest 
are  desired,  a  very  large  coil  is  preferable  to  a  static  machine. 

One  of  the  static  machines  at  the  Boston  City  Hospital  has  been  in  constant 
use  for  more  than  four  years.  The  custom  is  to  start  the  machine  in  the  morning 
and  let  it  run  nearly  all  day,  the  speed  being  somewhat  slower  when  the  machine 
is  not  in  actual  use.     Whenever  it  is  desired  to  excite  the  vacuum  tube,  it  is  only 


APPENDIX 


^Z7 


necessary  to  pull  a  cord  to  open  the  circuit,  and  lower  this  cord  when  it  is  desired 
to  close  the  circuit. 

If  the  machine  is  in  constant  use  and  enclosed  in  a  case,  an  acid  substance, 
which  is  a  conductor,  collects  on  the  plates  ;  therefore  they  should  be  cleaned  at 
intervals  with  a  cloth  wet  with  ammonia  water  wound  on  a  stick  and  held  against 
them  as  they  revolve. 

Static  machines  with  a  few  large  plates  such  as  the  one  described  on  pages  9-13 
occupy  much  space  and  are  expensive.  But  quite  as  good,  perhaps  better,  results 
can  be  had  with  machines  of  smaller  size  with  a  large  number  of  plates.  The 
machine  should  give  a  stream  of  sparks  of  sufficient  length  to  overcome  the  resist- 
ance of  a  high  tube,  or  the  resistance  of  the  multiple  spark  gap  when  that  is  used 
with  a  tube  of  low  resistance.  In  short,  the  requisites  for  a  satisfactory  machine 
that  will  permit  the  use  of  tubes  of  low  resistance,  which  are  more  desirable,  as  a 
rule,  than  those  of  high  resistance,  are  voltage  enough  to  give  a  spark  of  good 
length  and  an  ample  supply  of  current. 

A  static  machine  of  the  Holtz  pattern  (the  Winishurst  is  not  so  susceptible  to 
moisture,  but  is  considered  less  powerful)  that  is  well  built,  has  ten  plates,  120 
centimetres  (4  feet)  in  diameter,  that  can  be  run  at  500  revolutions  per  minute, 
will  probably  fulfil  very  well  the  requirements  of  a  hospital  or  of  a  practitioner 
who  desires  to  pursue  X-ray  work.  At  the  Boston  City  Hospital  there  are  now 
two  such  machines  that  can  be  used  independently,  or  as  one  machine  of  20 
plates. 

While  X-ray  apparatus  of  moderate  power  is  being  used  with  success  for  many 
purposes,  it  is  nevertheless  true  that  the  most  difficult  kinds  of  X-ray  work  can 
only  be  well  done  with  excellent  apparatus. 

Coils.  —  For  photographic  work,  a  coil  with  a  simple  form  of  interrupter,  such 
as  the  hammer,  run  by  a  low  voltage  current,  such  as  may  be  obtained  from  a 
storage  battery,  has  from  the  beginning  yielded  and  continues  to  yield  good 
results.  The  excellent  pictures  taken  by  Professor  Goodspeed  some  years  ago 
were  made  by  such  a  coil  with  a  mechanical  interrupter.  When  currents  of  high 
voltage  are  used  a  suitable  interrupter  (see  pages  20-23)  is  difficult  to  find.  The 
electrolytic  interrupter,  especially  the  form  devised  by  Wehnelt,  was  considered 
a  decided  advance  over  its  predecessors,  as  with  it  a  large  amount  of  energy 
could  be  sent  through  the  tube.  I  have  found  the  one  devised  by  Heinze  fairly 
satisfactory.  The  disadvantages  of  electrolytic  interrupters  are:  that  if  the 
apparatus  is  constantly  used,  the  platinum  wire  of  the  interrupter  wears  rapidly 
and  the  amount  of  the  current  which  passes  through  the  tube  diminishes  — 
the  wire,  however,  can  then  be  slid  down  a  little  farther ;  it  is  difficult  to  get 
tubes  adjusted  to  this  form  of  interrupter  on  very  large  coils,  and  the  tubes  do 
not  last  as  long  as  when  used  on  some  other  form  of  exciter.  These  coils  do 
not  give  as  steady  a  light  as  the  static  machine,  but  they  have  the  advantage  of 
taking  photographs  more  quickly. 

Coils  of  30  centimetres  (12  inches)  can  do  good  work,  but  the  time  of  exposure 
required  to  take  a  radiograph  is  much  less  when  larger  coils  are  used.  The  larger 
the  coil,  and  the  stronger  the  current  sent  through  it,  the  shorter  will  be  the  expos- 


638     THE    ROENTGEN    RAYS    IX    MEDICINE   AND    SURGERY 

ure  required ;  tubes,  however,  will  be  used  up  the  more  quickly  the  larger  the 
coil.  The  case  is  somewhat  analogous  to  that  of  the  railroad  train,  the  addition 
of  ten  miles  an  hour  to  a  good  speed  requires  in  an  increased  ratio  a  greater 
expenditure.  Similarly,  with  the  large  coil.  When,  however,  instantaneous  pic- 
tures are  required  this  expenditure  must  be  met,  but  the  price  that  must  be  paid 
to  obtain  short  exposures  is  greater  than  most  work  requires. 

A  50-centimetre  (20-inch)  coil  is  a  good  size  for  hospitals. 

Portable  Apparatus.  —  A  good  form  of  apparatus,  which  is  as  portable  as  a 
trunk,  is  a  40-centimetre  (16-inch)  Ritchie  coil,  with  a  hammer  interrupter,  that 
is  run  by  a  current  of  8  volts  from  a  storage  battery. 

Static  Machine  compared  with  Coils  :  for  fluoroscopic  examinations  0/  the  chest: 
comparative  value  of  fluorescent  screen  and  X-ray  photograph  for  chest  exami- 
nations. —  My  experience  teaches  me  that  static  machines  are  far  superior  to  coils 
for  fluoroscopic  examinations  of  the  chest,  because  they  give  a  perfectly  steady 
light  of  excellent  character,  whereas  that  from  a  coil  is,  as  a  rule,  unsteady. 
Only  those  who  have  used  a  large  static  machine  for  these  examinations  can 
appreciate  what  a  value  this  method  has.  Examinations  of  the  chest  with  the 
fluorescent  screen  satisfy  the  needs  of  the  practitioner  more  fully  than  those  with 
the  X-ray  photograph  (see  pages  99,  120,  169-170,  270,  328,  334-337),  there- 
fore a  static  machine  is  far  better  for  examining  the  chest.  Fluoroscopic  exami- 
nations should  of  course  be  recorded  as  described  on  pages  77  to  81,  and  as 
shown  in  Figs.  79,  82,  83,  153,  168,  169,  etc. 

TABLE    SHOWING    SOME    OF    THE    RESPECTIVE    ADVANTAGES    AND 
DISADVANTAGES    OF    STATIC    iMACHINE   AND   COIL 


Static  Machine 


Coil 


Advantages 


Perfectly  steadvliojht. 


Tubes  of  lower  resist- 
ance (except  with 
large  coils)  and 
ranging  over  wider 
limits  of  resistance 
can  be  used. 

Light  excellent  for 
fluoroscopic  work. 


Independent  of  elec- 
tric main. 


Disadv.^ntages 


\'ery  susceptible  to 
moisture. 

Longer  exposure 
needed  for  photo- 
graphic work. 


Large  one  is  more 
expensive  than 
coil. 


Advantages 


Disadvantages 


Not  affected  by  ;  Light  is  unsteady, 
moisture. 


Shorter  exposure 
for  photographic 
work. 


Range  of  resistance 
for  tubes  narrow 
and  tubes  do  not 
last  as  Ions:. 


More    powerfiil    for    As  a  rule,  ill  adapted 


amount  of  money 
expended. 


to  fluoroscopic 
work. 


Occupies     smaller     Interrupter  wears. 
space.  j 


APPENDIX 


639 


In  short,  moisture  is  the  chief  source  of  trouble  with  static  machines,  the 
interrupter  with  coils. 

The  practitioner  uses  the  X-ray  for  three  kinds  of  work:  (i)  photographic, 
(2)  fluoroscopic,  and  (3)  therapeutic;  the  coil  has  the  advantages  of  shorter 
exposures  for  the  first,  but  is  not  adapted  to  the  second  ;  the  static  machine  is 
the  best  for  the  second,  and  either  can  be  used  for  the  third,  but  the  static  machine 
is  safer  for  the  patient.  The  static  machine  and  the  A.  W.  L.  coil  may  be  used 
where  it  is  desired  to  employ  electrotherapeutic  treatment. 

The  practitioner  must  be  guided,  in  his  choice  of  an  apparatus,  by  the  kind 
of  work  he  chiefly  desires  to  do  ;  by  the  climate,  and  by  the  source  of  electrical 
supply;  that  is  whether  or  not  an  electric  main  is  at  hand.  If  one  is  available 
whether  it  affords  a  direct  or  an  alternating  current ;  if  the  former,  of  what 
voltage  ? 

Intensifying  Screens.  —  Intensifying  screens  have  been  used  with  brilliant 
success  for  taking  instantaneous  photographs  of  the  chest,  especially  by  Ziemssen 
and  Rieder  ;  ^  the  second  and  third  parts  of  their  book  are  even  more  commend- 
able than  the  first  part ;  but  much  time  and  expense  are  necessary  to  carry  out 
this  photographic  method,  and  therefore  it  is  less  adapted  to  the  needs  of  daily 
practice  than  the  fluoroscopic  examination ;  moreover,  for  the  practitioner's  pur- 
pose, the  information  they  afford  is  often  not  as  full;  but  both  methods  have  in- 
dispensable fields  of  usefulness. 

Tubes  of  high  resistance  are  most  suitable  when  intensifying  screens  are  used, 
yet  a  tube  of  low  resistance  is  necessary  when  it  is  desired  to  differentiate  between 
the  tissues  ;  but  the  light  from  such  tubes  may  have  too  little  penetration  to 
produce  instantaneous  pictures  even  when  an  intensifying  screen  is  used  :  hence 
slight  increase  of  density  in  tuberculosis,  for  instance,  may  not  be  so  well  detected 
by  photographs  taken  in  such  a  way,  as  by  those  made  with  a  tube  of  low  resist- 
ance without  an  intensifying  screen  and  given  a  longer  exposure,  especially  if 
these  photographs  are  taken  while  a  full  breath  is  held,  as  they  should  be.  (See 
page  250.) 

Stereoscopic  Fliioroscope.  —  Mackenzie  Davidson  was,  I  believe,  the  first  to 
devise  and  use  the  stereoscopic  fluoroscope.  Eugene  W.  Caldwell  has  employed 
a  most  ingenious  form  of  stereo-fluoroscopic  apparatus  which  he  has  fully  de- 
scribed in  the  Electrical  Review  for  November  16,  1 901. 

Tube  and  Regulator.  —  The  automatic  regulator  shown  in  Fig.  38,  page  45,  is 
an  efficient  one,  and  especially  useful  for  therapeutic  work.  When  a  light  of  great 
penetration  is  desired,  comparatively  little  of  which  would  be  absorbed  on  the 
surface  of  the  bodv,  such  a  light  as  is  shown  in  the  tube  marked  2,  Fig.  39,  page 
48,  the  movable  rod  of  the  regulator  should  be  drawn  out  until  the  distance 
between  its  right-hand  end,  as  seen  in  Fig.  38,  and  the  cross  is  considerable 
When  a  light  of  less  penetration  is  desired,  most  of  which  would  be  absorbed 
before  passing  through  the  hand,  the  distance  between  the  right-hand  end  of  the 
rod,  as  seen  in  Fig.  38,  and  the  cross  should  be  comparatively  short.  Ordinarily, 
I  use  a  resistance  of  i  mm.  to  i  cm.,  measured  as  described  on  page  42. 

1  Die  Roenfgographu  2u  der  runerin  Medicin.     Wiesbaden.     Published  by  J.  H.  Bergmann. 


640     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

With  a  static  machine  an  automatic  regulator  is  not  needed.  If  the  tubes  are 
of  low  resistance,  when  new,  they  may  be  used  for  a  number  of  hours  daily  for 
more  than  two  weeks  without  using  even  an  ordinary  regulator. 


TIMES   OF   EXPOSURE   FOR  X-RAY   PHOTOGRAPHS 

I  did  not  give  a  table  of  times  of  exposure  for  taking  X-ray  photographs  of 
various  parts  of  the  body  in  the  first  edition  because  different  forms  of  X-ray 
apparatus  vary  greatly  in  strength ;  and,  as  no  one  table  would  apply  to  all  of 
these,  it  seemed  better  to  let  each  observer  determine  this  time  by  experiment 
with  his  own  apparatus.  But  experience  has  shown  me  that  some  table,  though 
imperfect,  is  better  than  none ;  I  believe,  too,  that  the  strength  of  the  apparatus 
used  is  becoming  greater  and  more  nearly  alike  than  formerly.  I  therefore  insert 
the  following  table,  which  may  be  of  service  when  an  apparatus  of  considerable 
power  is  used  and  a  tube  of  low  resistance,  that  gives  a  good  light ;  that  is  to  say, 
when  the  light  is  of  such  a  quality  that  it  does  not  diminish  much  in  brilliancy  on 
the  fluorescent  screen  when  the  hand  is  examined  at  a  distance  of  153  centimetres 
(5  feet)  from  the  tube  as  compared  with  that  seen  when  the  hand  is  examined  at 
a  distance  of  54  centimetres  (18  inches)  from  the  tube  :  — 


Hands,  feet 

Forearm,  ankle 

Elbow,  leg,  arm 

Knee,  thigh 

Chest 

Shoulder 

Head 

Kidney 

Hip 


about  2  minutes 

about  3  to  4  minutes 
about  4  minutes 
about  4  to  5  minutes 
about  4  to  5  minutes 
about  5  minutes 
about  5  minutes 
about  4^  to  7  minutes 
about  5  to  8  minutes 


Tube  66  centimetres  (26  inches) 
from  plate 


Resistance  of  tube  less  than   i 
millimetre  to   i  centimetre 


Thinner  parts  require,  of  course,  less  exposure  than  thicker  and  denser  parts. 
With  the  thicker  parts  too  long  an  exposure  causes  fogging,  perhaps  by  diffusion 
of  the  light  through  the  tissues ;  for  example,  if  an  exposure  of  six  minutes  is 
right  for  a  hip,  ten  minutes'  exposure  would  give  a  fogged  plate.  Diaphragms 
over  the  part  and  on  the  opposite  side  from  the  plate  are  an  aid  in  preventing 
fogging,  which  occurs  more  readily  with  tubes  of  high  than  with  those  of  low 
resistance. 

Fluorometer.  —  To  those  who  are  making  a  study  of  the  uses  of  the  X-rays  the 
value  of  a  simple  instrument  for  determining  the  amount  of  rays  issuing  from  a 
given  vacuum  tube  is  obvious.  There  are  several  ways  in  which  this  measurement 
may  be  made ;  I  have  chosen  the  following,  which  depen(is  upon  the  distance 
that  a  tungstate  of  calcium  screen  must  be  held  from  a  given  vacuum  tube,  in 
order  that  the  illumination  from  it  may  equal  that  from  a  radio-active  substance 
which  has  been  measured  by  a  standard  source  of  light.     The  radio-active  sub- 


APPENDIX 


641 


stance  with  which  I  experimented  was  radium  (Curie)  that  was  most  kindly  placed 
at  my  disposal  by  Dr.  Rollins.  I  found  that  when  a  tungstate  of  calcium  screen 
with  the  radium  lying  upon  it  was  placed  over  a  vacuum  tube  in  a  dark  room  and 
the  X-rays  allowed  to  strike  it,  the  radium  was  less  bright  than  the  luminous  screen  • 


Fig.  391.  Fluoromefer.  Instrument  for  determining  the  amount  of  fluorescence  produced  by 
different  vacuum  tubes  on  the  tungstate  of  calcium  screen,  and  also  for  determining  the  quality  of  dif- 
ferent tungstate  of  calcium  screens.  The  cut  shows  the  section  of  a  Rollins  box  and  of  a  vacuum  tube, 
the  anode  of  which  is  at  A.  The  broken  lines  originating  at  A  represent  the  rays  given  off  at  the 
anode.  At  the  right  of  the  cut  is  shown  a  cardboard  tube  T,  the  interior  of  which  is  black,  and  in  the 
lower  end  of  which  is  a  small  oval  screen  ^'  of  tungstate  of  calcium ;  across  this  screen  is  fastened  a 
sealed  glass  tube  /?,  8  centimetres  long,  containing  some  radium  (Curie),  and  under  it  a  strip  of 
dark  cardboard.  This  screen  has  been  put  at  an  angle  in  the  tube  in  order  that  the  instrument  may 
be  used  without  exposing  the  eye  and  the  hand  to  the  X-rays.  To  determine  the  amount  of  fluores- 
cence produced  on  the  tungstate  of  calcium  screen  by  a  given  tube,  the  room  should  be  darkened  ;  the 
tube  7"  should  be  held  near  the  top,  its  opening,  the  rim  of  which  is  made  soft  by  a  covering  of 
velvet,  placed  close  to  the  eye,  and  its  other  end  at  such  a  distance  from  the  anode  of  the 
vacuum  tube  that  the  radium  appears  as  a  bright  band  on  the  less  bright  screen;  then  the  cardboard 
tube  should  be  brought  gradually  nearer  the  anode  until  a  point  is  reached  at  which  the  amount  of 
light  from  the  radium  A*  and  the  screen  5  is  about  equal  (or  the  point  when  the  band  of  light  from  the 
radium  is  just  disappearing  maybe  chosen).  The  distance  between  the  radium  and  the  anode  should 
then  be  measured  and  noted.  Vacuum  tubes  may  thus  be  tested  and  the  differences  between  them 
determined.  By  using  a  tube,  the  brilliancy  of  which  has  been  thus  determined,  tungstate  of  calcium 
screens  can  also  be  thus  tested  and  their  different  degrees  of  brightness  measured.  The  brightness  of 
the  radium  can  be  measured  in  terms  of  a  known  standard  by  a  photometer,  and  then  by  means  of  a 
fluorometer  the  tube  and  the  screen  can  be  referred  to  the  same  standard. 

but  that  as  the  screen  was  moved  farther  away  from  the  vacuum  tube  the  bright- 
ness of  the  screen  diminished  until  a  point  was  reached  at  which  the  screen  was 
less  bright  than  the  radium  ;    that  then  by   approaching  the  screen   gradually 

2  T 


642      THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

nearer  the  vacuum  tube  a  point  was  found  at  which  the  radium  and  the  screen 
were  about  ecjually  bright.  I  experimented  with  several  vacuum  tubes  in  this  way 
and  found  that  the  distance  at  which  the  screen  and  the  radium  were  about  equally 
bright  was  different  with  different  tubes,  the  limit  of  variation  being  between  10 
and  41  centimetres  ;  and  the  distance  was  constant  for  the  same  tube  under 
the  same  conditions.  I  then  made  a  simple  instrument  by  means  of  which 
the  distance  from  a  vacuum  tube  at  which  the  light  from  the  radium  and  the 
screen  are  about  equal  in  brightness  could  be  determined  and  thus  the  amount 
of  fluorescence  produced  on  the  screen  by  a  given  tube  be  measured.  This 
instrument  can  also  be  used  to  test  the  quality  of  the  tungstate  of  calcium  screens. 
In  both  tests  the  radium  is  the  constant ;  and  in  the  latter  test  the  amount  of 
fluorescence  produced  by  a  given  tube  must  first  be  determined  in  order  that  the 
quality  of  the  screen  may  be  the  only  unknown  quantity.  I  have  called  this 
instrument  a  fluorometer.     (See  Fig.  391.) 

To  use  this  instrument  as  a  standard  of  measurement  the  radio-active  sub- 
stance must  be  compared  with  the  standard  of  light.  Mr.  R.  R.  Lawrence, 
Assistant  Professor  of  Electrical  Engineering  in  the  Massachusetts  Institute  of 
Technology,  has  kindly  tested  the  radio-active  substance  (radium)  that  I  have 
used,  and  this  test  indicated  that  the  light  it  gave  out  was  equal  to  that  from  a 
white  surface  when  illuminated  by  a  standard  candle  at  a  distance  of  about  5 
metres  (16  feet).  A  more  accurate  determination  might  be  made  by  using 
in  the  photometer  a  light  more  nearly  similar  to  that  given  out  by  the  radium 
than  was  then  at  his  disposal.  As  by  means  of  a  photometer  the  amount  of  light 
given  off  by  the  radium  can  be  measured  in  terms  of  a  known  standard,  so  the 
amount  of  fluorescence  produced  on  a  tungstate  of  calcium  screen  by  a  given  tube 
and  the  brightness  of  which  a  given  screen  is  capable  may  both  eventually  be 
referred  to  the  same  standard. 

The  fluorometer  may  serve  as  a  basis,  with  a  given  apparatus,  for  determining 
the  length  of  exposures  when  the  X-rays  are  used  as  a  therapeutic  agent,  and 
likewise  when  they  are  employed  for  taking  radiographs. 


PRECAUTIONS    TO    BE   TAKEN    BY    THOSE   USING   THE   X-RAYS 

Every  one  who  uses  an  X-ray  apparatus  should  recognize  the  importance  of  i 
protecting  himself  from  the  rays.  ' 

I  St.  The  tube  should  be  enclosed  in  a  tube  holder,  painted  with  many  coats' 
of  white  lead,  as  pointed  out  by  Rollins,  which  obstructs  the  passage  of  the  rays  '. 
and  only  allows  them  to  pass  where  an  opening  has  been  made  for  them. 

2d.  The  box  of  the  fluoroscope  should  be  coated  with  the  same  material, 
and  the  fluorescent  screen,  at  its  base,  covered  with  a  plate  of  thick  lead  glass 
to  protect  the  eyes  of  the  observer,  as  suggested  by  Rollins.'  Or  a  much  smaller 
piece  of  thick  lead  glass  may  be  placed  inside  the  box  just  below  its  apex. 

3d.   The  amount  of  the  light  from  the  tube  may  be  tested  by  a  fluorometer. 

^  Electrical  Review,  June  14,  1902. 


APPENDIX 


643 


There  are  risks  to  the  practitioner  if  he  attempts  to  estimate  the  amount  of 
X-rays  coming  through  the  Croolces'  tube  by  watching  the  image  of  his  hand  on 
the  fluorescent  screen.  If,  however,  he  so  tests  the  hght,  he  should  ahvays  stand 
at  a  distance  of  six  feet  from  the  tube. 

Cases  have  been  reported  of  epitheliomatous  growths  arising  in  the  scar  of 
burns  produced  by  the  X-rays  on  persons  using  the  apparatus.  I  have  seen  one 
case  of  a  medical  man  who,  after  following  the  action  of  vacuum  tubes  excited  by 
a  coil  for  two  or  three  months,  suffered  from  acute  choroiditis.  This  affection 
may  or  may  not  have  been  caused  by  the  X-rays,  but  it  is  quite  possible  that  they 
produced  it,  and  that  they  can  cause  other  injuries  to  the  eyes ;  therefore  no 
unnecessary  risk  should  be  run. 

METHOD    OF   DETERMINING  ANGLE  AT  WHICH  THE   LIGHT  PASSES 
THROUGH    THE    BODY    WHEN    THE    PATIENT    IS    EXAMINED 

Not  infrequently  in  making  a  fluoroscopic  examination  of  the  chest,  for  example, 
it  is  an  advantage  to  be  able  to  turn  the  patient  for  the  purpose  of  making  the 
examination  with  the  light  going  through  the  chest  first  in  one  direction  and  then 
in  another.  It  is  also  desirable  to  have  some  simple  way  of  knowing  at  what 
angle  the  light  is  passing  through  the  chest  or  certain  portions  of  it,  especially 
when  the  central  portion  of  the  thorax  above  the  level  of  the  heart  is  being 
examined.  This  end  I  have  accomplished  in  various  ways,  and  one  of  the 
simplest  seems  to  be  the  manner  illustrated  in  the  accompanying  cut. 

An  arm  of  wood  is  hooked  over  the  top  of  the  tube  holder  and  is  held  by  two 
small  pins  which  enter  holes  in  the  back  of  the  tube  holder.  In  this  wooden  arm 
there  is  a  spirit  level,  near  TS,  which  does  not  show  in  the  cut,  and  near  the 
front  edge  of  the  tube  holder  a  wooden  thumb  screw  (TS)  by  means  of  which 
the  end  of  the  arm  toward  the  patient  may  be  raised  or  lowered.  The  screw  is 
turned  while  watching  the  level,  until  the  arm  is  brought  into  a  horizontal  plane. 
In  the  middle  of  that  portion  of  the  arm  which  is  immediately  above  the  top  of 
the  tube  holder  is  an  opening  2  centimetres  in  diameter.  By  looking  down 
through  this  opening  into  the  tube  holder  the  observer  can  see  the  anode  of  the 
Crookes'tube  and  then  can  move  the  tube  until  the  anode  is  brought  exactly 
under  the  centre  of  this  opening  in  the  arm. 

Between  the  tube  holder  and  the  patient  there  are  two  vertical  pieces  of  wood 
which  may  be  slid  in  a  slot  on  the  arm.  The  one  of  these  nearer  the  tube  holder 
carries  a  flat  iron  ring  having  an  opening  about  2  centimetres  in  diameter,  and  the 
other,  which  is  nearer  the  patient,  has  a  lead  bullet  about  ii  centimetres  in 
diameter.  The  centre  of  the  iron  ring  and  of  the  lead  bullet  are  on  a  level  with 
the  central  axis  of  the  Crookes'tube. 

If  the  adjustments  above  described  have  been  properly  arranged,  and  the 
observer  places  his  fluoroscope  between  himself  and  the  end  of  the  arm,  he  will 
see  on  the  fluorescent  screen  a  shadow  of  the  bullet  surrounded  by  a  light  area, 
and  around  that  the  shadow  cast  by  the  iron  ring ;  that  is,  the  centre  of  the 
bullet,  the  centre  of  the  ring,  and  the  anode  are  all  in  the  same  horizontal  line. 


644     'i^HE    ROENTGEN    RAYS    IX    MEDICINE   AND    SURGERY 


Fig.  392.  Cut  illustrating  method  of  determining  the  angle  at  which  the  light  was  passing 
through  the  body  when  the  patient  was  examined.  TS,  thumb  screw;  A*,  ring;  Z?,  bullet;  T,  tube 
holder  with  iris  diaphragm  ;  /-*  (under  the  chair)  indicates  the  zero  of  the  graduated  circle  on  the  disk 
which  rests  on  the  middle  support  of  the  chair,  and  may  be  turned  by  hand  about  it.  The  pointer  is 
fastened  to  the  seat  of  the  chair  and  turns  with  it. 


The  patient  is  then  seated  in  a  swivel  chair,  which  has  a  straight  leather  back, 
as  described  on  page  73,  and  the  tube  holder  is  so  placed  that  the  centre  of  the 
shadow  of  the  bullet  is  seen  over  the  centre  of  the  spinal  column  and  over  the 
centre  of  the  sternum.  Then  the  tube  holder  may  be  raised  or  lowered  to  bring 
the  shadow  of  the  bullet  on  a  level  with  the  fourth  rib,  still  keeping  it  in  the 
median  line  of  the  body. 

The  disk  under  the  patient  (see  Fig.  392),  which  carries  a  graduated  circle, 
rests  on  the  feet  of  the  chair  and  does  not  turn  when  the  upper  portion  of  the 
chair  is  turned.  When  the  patient  is  seated  and  has  been  brought  into  the  posi- 
tion which  brings  the  shadow  of  the  bullet  over  the  median  line  on  a  level  with 
the  fourth  rib,  as  described  above,  the  disk  is  moved  around  the  pivot  attached 


APPENDIX 


645 


to  the  feet  of  the  chair  until  the  zero  of  the  scale  (P)  is  directly  under  the 
pointer,  which  is  attached  to  the  seat  of  the  chair  and  moves  with  it.  The  physi- 
cian then  seats  himself  in  the  low  chair  near  the  patient  and  makes  an  examina- 
tion of  the  thorax.  To  make  a  second  examination  from  another  point  of  view 
he  turns  the  chair  and  again  studies  the  appearances  on  the  fluorescent  screen. 
He  then  reads  off  on  the  scale  the  angle  at  which  the  second  examination  was 
made  by  noting  the  number  on  the  circle  of  the  disk  over  which  the  pointer  lies. 
For  example,  if  the  physician  wishes  to  examine  more  fully  than  can  be  done  in 
the  position  shown  in  the  cut  the  left  side  of  the  descending  arch  of  the  aorta,  or 
the  top  of  the  transverse  portion  of  the  arch,  he  has  only  to  turn  the  chair  so  as 
to  bring  the  right  shoulder  of  the  patient  toward  himself  and  the  left  nearer  the 
tube,  and  when  he  has  found  exactly  the  position  at  which  these  portions  of  the 
aorta  are  brought  out  most  clearly  on  the  fluorescent  screen,  —  in  some  cases  about 
35  degrees,  —  he  may  read  the  angle  at  which  the  light  is  going  through  the  body, 
by  noting  the  number  on  the  scale  to  which  the  pointer  was  moved  when  the  chair 
was  turned  from  its  position  over  the  zero. 

By  this  method  the  practitioner  has  a  ready  way  of  determining  the  angle  at 
which  the  light  was  passing  through  the  body  when  a  given  organ  or  organs  were 
observed  on  the  fluorescent  screen.  A  record  of  this  angle  should  then  be  made 
on  the  tracing  cloth  on  which  the  practitioner  has  traced  the  outlines  he  has  first 
drawn  on  the  skin  of  the  patient. 

When  the  examination  is  over  and  the  practitioner  desires  to  remove  the 
wooden  arm  and  put  it  away  until  it  is  needed  again,  it  is  only  necessary  to  push 
it  back  about  one-half  a  centimetre,  in  order  to  free  the  pins  attached  to  the  arm 
and  holding  it  to  the  tube  holder,  and  then  lift  the  arm  off. 

HEAD   AND   NECK 

With  the  better  forms  of  apparatus  now  at  our  disposal  and  with  greater 
experience  more  can  be  learned  of  nearly  all  parts  of  the  head  and  neck  from 
X-ray  photographs  than  was  formerly  possible. 

Dr.  Charles  K.  Mills  and  Dr.  G.  E.  Pfahler^  report  a  second  case  (see  page 
340)  in  which  a  tumor  of  the  brain  was  localized  by  the  X-rays  in  the  living 
person.  In  this  case,  as  in  the  one  reported  by  Church,  the  bones  of  the  cranial 
vault  were  very  thin.  Dr.  Mills  first  localized  the  tumor  by  clinical  study,  and 
then  Dr.  Pfahler  made  an  X-ray  picture  of  this  part  of  the  head.  The  negative 
showed  good  detail  of  all  the  structures,  such  as  the  scalp,  the  outer  and  inner 
table  of  the  skull,  the  frontal  sinuses,  the  coronal  suture,  and  the  groove  of 
the  posterior  meningeal  artery.  Between  this  suture  and  artery  was  a  large 
shadow  that  corresponded  to  the  area  in  which  Dr.  Mills  had  located  the  tumor. 

The  patient  was  a  colored  woman,  thirty-two  years  of  age,  and  therefore  for 
comparison  another  colored  woman,  an  epileptic  of  the  same  age,  was  chosen  and 

1  "Tumor  of  the  brain  localized  clinically  by  the  Roentgen  rays.  With  some  observations 
and  investigations  relating  to  the  use  of  the  Roentgen  rays  in  the  diagnosis  of  lesions  of  the 
brain,"   Philadelphia  Medical  Journal,  YthxViZxy  %,  1902,  pp.  268-273. 


646     THE    ROENTGEN    RAYS   IN    MEDICINE   AND    SURGERY 

a  similar  X-ray  exposure  made  of  her  head.  The  resulting  negative  and  a  second 
one,  taken  later,  did  not  show  a  shadow  corresponding  to  the  one  seen  in  the 
nef^ative  taken  from  the  patient.  Dr.  Pfahler  likewise  took  another  negative  of 
the  head  of  the  patient  and  obtained  the  same  shadow  as  before.  Its  definite 
oudine  in  the  upper  portion  seemed  to  indicate  that  the  tumor  was  superficial 
and  therefore  removable.  Dr.  Mills  hesitated  about  advising  an  operation  because 
he  believed  that  the  neoplasm  was  in  large  part  subcortical,  but  as  he  knew  that 
enucleable  encapsulated  tumors  of  considerable  size  in  this  and  other  regions 
were  operable,  and  that  operation  gave  a  chance  of  success  in  an  otherwise  hope- 
less case,  he  finally  advised  surgical  interference.  He  was  likewise  influenced 
somewhat  by  the  patient,  whose  sufferings  were  so  terrible  that  she  urged  opera- 
tion. An  operation  was  done  and  the  upper  portion  of  the  new  growth,  which 
corresponded  in  position  to  the  upper  part  of  the  shadow,  was  removed.  The 
autopsy  showed  a  large  subcortical  portion  of  the  tumor  corresponding  to  the 
remainder  and  less  definite  part  of  the  shadow. 

A  microscopical  examination  proved  this  tumor  to  be  a  fibrosarcoma.  At 
Dr.  Mills's  suggestion,  Dr.  Pfahler  made  some  experiments  on  the  cadaver.  He 
placed  in  different  portions  of  the  brain  a  tumor,  hoping  to  prove  by  means  of 
X-ray  negatives  that  it  could  be  shown  in  any  of  the  usual  locations.  From 
these  experiments  he  draws  the  following  conclusions  :  — 

"  I.  That  fibrosarcomata,  and  probably  other  tumors,  can  be  photographed  in 
the  living  subject  and  their  location  and  extent  shown. 

2.  That  various  tumors  can  be  photographed  in  their  most  common  locations. 

3.  That  other  abnormalities  and  deficiencies  in  brain  tissue  itself  can  be 

photographed,  which  will  probably  be  of  value  in  the  diagnosis  of  cysts, 
softening,  and  hemorrhages. 

4.  That  over-exposure  of  the  third   series   (of  negatives)   and  the  under- 

exposure of  the  fourth  show  that  good  results  will  only  follow  the  most 
careful  technique  and  keen  judgment  as  to  the  special  conditions  in 
each  case. 

5.  That  the  shadows  obtained  in  normal  parts  of  the  brains  studied  indicate 

that  great  care  is  necessary  in  the  interpretation  of  any  shadow  obtained 

in  the  living  subject." 
Dr.  Charles  K.  Mills  and  Dr.  G.  E.  Pfahler^  report  another  case  of  tumor  of 
the  brain  located  clinically  and  also  by  the  X-rays.  An  operation  was  done,  and 
the  tumor,  which  was  of  enormous  size  and  encapsulated,  was  removed.  The 
microscopical  examination,  made  by  Dr.  Spiller,  showed  that  it  was  a  spindle- 
celled  sarcoma. 

Dr.  Mills  believes  that  the  gravest  dangers  in  operations  for  brain  tumors  are 
hemorrhage  and  a  prolonged  operation,  and  that  the  lack  of  success  in  removing 
these  tumors  is  due  largely  to  the  fact  that  the  operation  is  not  performed  at  a 
sufficiently  early  date,  and  that  the  trephine  openings  are  usually  too  small.  He 
concludes  by  saying  that  the  X-rays  should  be  used,  as  well  as  the  other  methods, 

^  "  An  additional  case  of  tumor  of  the  brain  localized  clinically  and  by  the  Roentgen  rays," 
Philadelphia  Medical  Journal,  September  27,  1902,  pp.  439-441. 


APPENDIX 


647 

in  making  a  diagnosis  of  tumor  of  the  brain  ;  that  if  the  diagnosis  is  clear  and 
the  tumor  is  presumably  in  an  accessible  area,  an  operation  should  be  performed 
immediately;  that  large  openings  should  be  made  in  the  skull  and  that  the 
operation  should  be  osteoplastic  in  order  not  to  leave  a  permanent  opening  in 
the  skull,  and  to  increase  the  chances  of  maintaining  the  vitality  of  the  bone  flap  ; 
that  preparation  should  be  made  to  perform  a  Crile  operation  for  temporary 
clamping  of  the  carotids  as  soon  as  hemorrhage  becomes  threatening,  and  that 
the  operation  in  some  cases  should  be  done  in  two  stages. 

FRONTAL   SINUS 

Dr.  John  Harold  Philip  ^  advocates  the  use  of  the  X-rays  as  an  aid  to  deter- 
mining the  limitations  of  the  frontal  sinus  previous  to  operation.  He  states  that 
Dr.  Howard  A.  Lothrop,  of  Boston,  after  carefully  examining  250  frontal  sinuses 
from  dissecting-room  material,  comes  to  the  conclusion  that  "  there  was  no  ex- 
ternal landmark  defining  the  superior  limit  of  the  sinus ;  that  the  external  angu- 
lar process  of  the  frontal  bone  was  not  often  the  limit  of  the  sinus  laterally ;  that 
in  the  majority  of  cases  the  septum  (between  the  sinuses)  deviated  to  one  side 
or  the  other  within  a  range  of  five  millimetres  or  even  more,  notwithstanding  its 
frequent  median  position  interiorly ;  that  the  plane  of  the  septum  was  roughly 
anteroposterior,  passing  between  the  anterior  and  posterior  surfaces,  but  occa- 
sionally it  might  so  deviate  that  one  sinus  would  lie  partly  overlapping  the  other, 
even  to  an  extent  of  two  centimetres ;  that  there  were  no  absolutely  certain 
guides  by  which  the  degree  of  development  of  the  frontal  sinus  in  the  adult  could 
be  determined  before  attempting  to  expose  it."  Dr.  Philip,  before  entering  a 
frontal  sinus,  obtained  three  frontal  bones  and  found  that  one  had  almost  no  sinus 
on  the  left  side  ;  that  the  sinus  on  the  left  side  in  another  extended  not  more 
than  three  millimetres  beyond  the  median  line  and  that  there  was  no  septum  and 
no  communication  with  the  left  nasal  cavity;  but  that  the  third  frontal  bone  seemed 
normal.      (See  pages  464  to  465.) 

THE  THORAX 

Emphysema 

In  one  case  of  emphysema  that  I  have  seen  the  heart  was  pushed  so  far  for- 
ward that  the  whole  of  its  posterior  border  could  be  followed  when  the  light 
went  through  the  chest  from  side  to  side,  and  it  was  pushed  so  strongly  against 
the  anterior  wall  of  the  chest  that  its  lateral  borders  could  of  course  be  more 
perfectly  defined  by  percussion  than  under  any  other  conditions. 

Pneumohydrothorax 

The  following  case  shows  that  all  the  usual  physical  signs  of  pneumohydro- 
thorax may  not  be  present  in  some  cases. 

i"The  X-ray  in  determining  the  limits  of  the  frontal  sinus,"  Jowual  of  the  American 
Medical  Association,  March  22,  1902,  pp.  764-765. 


648  THE  ROENTGEN  RAYS  IN  MEDICINE  AND  SURGERY 

A.  B.,  fifU'  years  of  age.  Diagnosis  pulmonary  tuberculosis  ;  pleurisy  with 
effusion  ;  2  litres  of  fluid  withdrawn  from  the  chest.  A  few  days  later  he  was 
examined  with  some  other  patients  who  had  pleurisy  with  effusion,  in  order  to 
compare  the  fluoroscopic  signs  seen  in  his  chest  with  those  observed  in  the  chest 
of  these  latter  patients.  To  my  surprise  I  found  the  X-rays  showed  that  A.  B. 
had  a  pneumohydrothorax,  but  careful  physical  examination  made  on  the  same 
and  on  the  following  days  failed  to  give  succussion  or  the  coin  sound.  The  front 
of  the  chest,  however,  below  the  level  of  the  nipple  when  the  patient  was  in  a 
sitting  position,  was  flat  to  percussion,  and  the  same  area  gave  good  resonance 
when  the  patient  was  in  a  prone  position. 


Pleurisy  with  Effusion.     Darkened  Area  in  the  Lower  Part 

OF  the  Thorax 

The  fluoroscope  shows  that  there  may  be  pleurisy  with  a  very  small  effusion 
in  the  outer  and  lower  portion  of  the  chest,  obscuring  a  part  of  the  outer  end  of 
the  diaphragm  and  at  the  same  time  a  friction  rub  may  be  heard  above  the  site 
of  the  effusion. 


W-~ 


Fig.  393.      Pleurisy  with  effusion  on  left  side. 


The  direction  of  the  line  indicating  the  upper  portion  of  the  shadow  cast  by 
moderate  amounts  of  pleuritic  effusion  varies  with  the  quantity  of  fluid  present  in 
the  chest. 


APPENDIX 


649 


Sitting  Position.  —  When  the  amount  of  effusion  is  moderate,  the  line  is  more 
nearly  vertical  than  when  the  chest  is  nearly  full  of  fluid. 

The  preceding  cut  shows  how  fluoroscopic  examinations  may  assist  in  distin- 
guishing between  fluid  in  the  pleural  sac  and  an  increased  density  in  the  lung. 

The  full  line  marked  "  prone  "  on  the  left  side  and  the  full  vertical  line  parallel 
with  the  line  of  the  sternum  indicate  about  the  limits  of  the  light  area  seen  on  the 
fluorescent  screen  when  the  patient  was  lying  on  his  back ;  the  line  marked 
"  sitting  "  and  the  vertical  line  of  the  same  character,  the  limits  of  the  light  area 
when  the  patient  was  sitting  and  facing  the  observer  squarely.  The  position  of 
the  light  with  reference  to  the  patient  was  the  same  in  both  these  examinations  ; 
that  is,  behind  the  patient,  70  centimetres  from  the  screen  and  opposite  the  point 
where  the  median  line  crosses  the  fourth  rib. 

The  line  marked  B  and  the  whole  of  the  vertical  line  indicate  the  limits  of  the 
light  area  when  the  patient  was  sitting  with  his  left  shoulder  turned  a  little  toward 
the  observer,  who  was  in  front  of  the  patient  in  all  three  cases. 

The  heart  line  marked  "  prone  "  shows  the  position  of  the  right  border  of  the 
heart  when  the  patient  is  lying  down,  and  the  one  marked  "sitting"  the  place  of 
this  border  when  the  patient  is  in  that  position.  In  both  these  cases  the  tube 
was  behind  the  patient,  70  centimetres  distant  from  the  fluorescent  screen,  and 
opposite  the  point  where  the  median  line  crosses  the  fourth  rib. 

It  is  not  always  easy  to  distinguish  by  physical  signs  between  a  liver  that  is 
higher  than  normal,  and  some  effusion  on  the  right  side  of  the  chest,  but  tliis  dis- 
tinction is  readily  made  by  a  fluoroscopic  examination. 

When  the  lower  portion  of  the  chest  is  slightly  darkened,  it  is  well  to  consider 
the  possibility  of  abnormal  conditions  just  below  the  diaphragm.  For  instance,  in 
one  case  I  saw  a  shadow  on  the  screen  in  the  lower  portion  of  the  thoracic  cavity 
in  a  patient  who  had  pus  in  one  of  her  kidneys,  and  after  the  pus  had  been  re- 
moved and  the  patient  had  recovered  from  the  operation,  this  portion  of  the  chest 
was  found  to  be  perfectly  clear. 

Heart 

One  way  in  which  fluoroscopic  examinations  assist  auscultation  is  in  determm- 
ing  the  position  of  the  heart  with  reference  to  the  anterior  thoracic  wall  both  in 
inspiration  and  expiration.  When,  for  example,  the  lower  portion  of  the  heart  is 
farther  from  the  chest  wall  than  usual,  we  may  find  that  the  murmurs  are  heard 
less  distinctly  than  we  should  expect  below  the  Hne  where  the  heart  and  chest 
wall  separate'.  Bv  determining  the  exact  position  of  the  heart  in  the  thorax,  both 
when  seen  in  the'fluoroscope  with  the  light  going  through  from  back  to  front  and 
also  with  the  light  going  through  from  side  to  side,  the  reason  why  the  heart 
sounds  are  transmitted  more  distinctly  in  one  place  on  the  chest  wall  than  m 
another  is  made  clear.  The  fiuoroscope  shows  that  in  one  case  the  heart  is  near 
the  chest  wall,  and  in  the  other  that  it  is  farther  away. 

Fluoroscopic  examinations  in  cardiac  disease  also  show  that  some  of  the  out- 
lines of  the  ventricles,  auricles,  pulmonary  artery,  or  ven^e  cavae  vary  from  ihe 
normal  as  would  be  expected.     (See,  for  example.  Fig.  179.  page  307-) 


6^0     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 


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APPENDIX 


651 


A  Comparison  between  a  Radiographic  and  a  Fluoroscopic 
Examination  in  a  Case  of  Dextrocardia 

Both  radiographic  and  fluoroscopic  examinations  of  the  chest  are  of  value  ; 
the  latter  method  is  coming  more  and  more  into  use,  especially  among  French 
physicians.  It  requires  a  perfectly  steady  light,  which  is  not  necessary  for  taking 
radiographs,  and  as  an  apparatus  giving  such  light,  namely,  a  powerful  static 
machine,  is  not  readily  obtained,  comparatively  few  physicians  have  had  the  op- 
portunity of  seeing  what  this  method  can  accomplish. 

A  comparison  between  the  two  methods  in  a  case  of  dextrocardia  in  a  girl 
aged  seven  years,  a  patient  of  Dr.  E.  P.  Joslin,  at  the  Boston  City  Hosi)ital,  who 
was  brought  to  me  for  X-ray  examination,  is  of  interest.  The  radiograph  gave 
the  position  of  the  heart  as  indicated  by  the  illustration  (see  Fig.  394),  but  the 
outline  of  this  organ  was  seen  with  greater  clearness  by  means  of  the  fluoroscope 
(see  Fig.  395)  ;  moreover,  the  characteristic  pulsations  of  the  left  ventricle  could 
be  watched  on  the  fluorescent  screen,  and  the  movement,  during  a  deep  inspira- 
tion, of  the  left  side  of  the  heart  downward,  and  to  the  left  instead  of  downward, 
and  to  the  right,  as  in  a  normal  individual,  could  be  observed.  That  is  to  say,  the 
fluoroscope  not  only  gave  the  same  information  as  the  radiograph,  but  also  added 
to  it ;  further,  the  fluoroscopic  examination  was  not  subject  to  the  delay  incident 
to  the  photographic  method.  On  the  other  hand,  the  radiograph  has  the  ad- 
vantage of  being  in  itself  a  permanent  record  that  can  be  filed  with  the  case  ; 
but  a  permanent  record  of  the  fluoroscopic  examination  may  also  be  made 
(see  Rg.  395)  and  filed  with  the  case  by  tracing  on  the  skin  the  appearances  seen, 
and  then  retracing  them  on  tracing  cloth, 

ABDOMEN 
Intestines 

Dr.  W.  B.  Cannon  ^  has  made  interesting  and  instructive  observations  on  the 
movement  of  the  food  through  the  intestines  by  watching  the  process  of  digestion 
in  this  portion  of  the  digestive  tract  of  cats,  and  he  has  found  that  the  antiperi- 
stalsis  in  the  large  intestine  may  force  a  nutrient  enema  into  the  small  intestme. 
The  food  used  in  these  experiments  was  mixed  with  subnitrate  of  bismuth  in  the 
proportion  of  one-tenth  to  one-third  of  its  weight.  Canned  salmon,  which  is 
much  liked  by  cats,  was  generally  used.  Dr.  Cannon  found  that  the  constrictions 
going  on  in  the  small  intestine  caused  the  food  to  divide  into  segments,  with  the 
result  that  it  was  mixed  with  the  digestive  juices  and  then  brought  into  contact 
with  the  absorbing  mechanism  ;  these  constrictions  also  emptied  the  venous  and 
lymphatic  radicles  of  their  contents  by  compression  of  the  intestinal  wall ;  peri- 
stalsis was  usually  combined  with  segmentation,  that  is,  as  the  food  moved  on 
constrictions  occurred  which  separated  one  end  from  the  main  body,  but  this 

1  "The  Movement  of  the  Intestines  studied  by  the  Roentgen  R^)%r  Ameriam  Journal 
of  Physiology,  Vol.  VI,  January  i,  1902,  No.  V. 


652      THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

separation  was  only  momentary,  for  the  two  masses  were  soon  united  again,  and 
the  combined  material  was  pushed  onward  until  another  constriction  repeated 
the  process  described  ;  the  iliocjecal  valve  was  competent  for  food  entering  the 
colon  from  the  ileum  ;  the  usual  movement  of  the  transverse  and  ascending  colon 


Fig.  395.  Reproduction  of  fluoroscopic  tracing  from  the  same  case  of  dextrocardia.  Fluo- 
rescent screen  on  front  of  chest.  The  two  full  lines  near  the  right  nipple  indicate  the  position  of  the 
border  of  the  left  ventricle  in  expiration  (outer  line)  and  inspiration  (inner  line),  respectively.  The 
horizontal  full  lines  indicate  the  position  of  the  diaphragm  in  deep  inspiration  ;  the  broken  lines,  paral- 
lel with  them,  in  expiration.     The  ends  of  the  clavicles  are  indicated  at  the  top  of  the  cut. 


APPENDIX 


65. 


and  c?ecum  was  an  antiperistalsis ;  the  food,  after  being  brought  into  a  closed 
sac,  was  thoroughly  mixed  by  constrictions  running  toward  the  caecum  and  again 
subjected  to  absorbing  walls  without  interfering  with  the  process  going  on  in  the 
small  intestine  ;  when  the  new  food  entered  the  large  intestine  a  strong  contrac- 
tion took  place  along  the  caecum  and  ascending  colon  which  pushed  some  of  the 
food  onward ;  this  contraction  was  followed  by  antiperistaltic  waves ;  as  the 
material  accumulated  in  the  transverse  colon,  tonic  constrictions  appeared  which 
carried  it  into  the  descending  colon,  leaving  the  transverse  and  ascending  por- 
tions free  for  the  antiperistaltic  waves,  and  then  it  was  carried  out  of  the  lower 
descending  colon  by  peristalsis  and  the  pressure  of  the  abdominal  muscles ;  the 
remainder  of  the  material  was  then  spread  into  the  emptied  tract  and  this  tract 
was  again  cleared.  Dr.  Cannon  states  that  his  observations  have  given  no  evi- 
dence of  antiperistalsis  in  the  small  intestine,  but  that  the  antiperistalsis  of  the 
large  intestine,  as  already  stated,  may  force  a  considerable  amount  of  a  large 
nutrient  enema  into  the  small  intestine,  and  that  the  segmentation  of  this  enema 
would  have  the  same  results  as  if  the  enema  had  passed  normally  through  the 
stomach.  The  movement  of  both  the  large  and  small  intestine  ceased  if  the 
cats  were  frightened,  distressed,  or  angry ;  but  these  movements  continued  dur- 
ing sleep. 

Subdiaphragmatic  Abscess 

The  following  case  illustrates  how  an  X-ray  examination  may  make  perfectly 
clear  a  diagnosis  previously  so  obscure  that  two  excellent  physicians  who  saw  the 
patient  independently,  prior  to  the  X-ray  examination,  did  not  recognize  the 
conditions  present. 

The  cut  (Fig.  396)  indicates  the  appearances  seen  in  the  right  side  of  the 
thorax  when  the  patient  was  sitting,  and  the  fluorescent  screen  was  on  the  front 
of  the  chest  and  the  tube  behind  him.  The  upper  part  of  the  right  side  was 
clear,  below  was  a  darker  area,  D  (Fig.  396),  the  shadow  cast  by  the  diaphragm ; 
below  this  again  a  light  tract,  and  then  a  very  dark  shadow.  The  horizontal  line 
dividing  the  light  area  (Gas,  Fig.  396)  from  the  dark  (Fluid,  Fig.  396)  remained 
level  when  the  patient  bent  his  body  from  side  to  side,  and  became  wavy  when  he 
was  gently  shaken.  These  observations  indicated  that  there  was  a  cavity  below  the 
diaphragm,  which  was  higher  than  normal,  containing  gas  and  fluitl,  the  light  area 
corresponding  to  the  gas  and  the  shadow  indicating  fluid. 

When  the  patient  was  examined  lying  on  his  back,  with  the  tube  and  fluores- 
cent screen  in  the  same  respective  positions  as  when  he  was  sitting,  the  lower 
right  side  of  the  thorax  appeared  to  be  filled  with  a  dark  mass,  rounded  above  ; 
that  is,  the  light  area  observed  in  the  sitting  position  was  obliterated  when  the 
patient  was  in  the  prone  position  as  the  fluid  distributed  itself  horizontally. 

An  examination  with  the  tube  opposite  the  middle  of  the  right  side  of  the 
patient,  so  that  the  light  could  pass  through  the  body  in  this  direction,  was  not 
attempted,  as  the  patient  was  too  weak  to  make  it  advisable  to  prolong  the 
examination. 


654     'i^I^E    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

An  operation  was  done  by  Dr.  John  C.  Munro,  at  the  Boston  City  Hospital, 
and  I  was  informed  that  my  X-ray  examination  was  confirmed  in  every  particular. 


''  ^4. 


V 


Fig.  396.  September  24, 1902,  X-ray  examination  with  patient  in  a  sitting  position.  Tube  behind 
the  back  and  fluorescent  screen  on  front  of  chest.  D,  right  diaphragm  ;  //,  heart.  Horizontal  line 
marking  the  top  of  the  fluid  remained  level  when  the  patient  bent  from  side  to  side,  and  became  wavy 
when  he  was  gently  shaken. 

Dr.  Weinberger '  has  given  an  excellent  radiograph  of  the  appearances  seen 
in  the  thorax  in  subdiaphragmatic  abscess. 


THERAPEUTIC    USES    OF   THE   X-RAYS 

Further  experience  with  the  X-rays  as  a  therapeutic  agent  both  in  this  country 
and  in  Europe  has  confirmed  their  value  in  this  field  of  medicine  and  has  shown 
that  as  such  they  have  a  wide  range  of  usefulness. 

Apparatus.  —  The  apparatus  required  is  either  a  good-sized  static  machine  or 
a  coil.  It  has  been  stated  that  static  machines  would  not  answer  the  purpose, 
and  that  the  therapeutic  uses  of  the  X-rays  could  only  be  carried  out  when  a  coil 
was  used  to  excite  the  vacuum  tube ;  either  will  answer,  however,  but  the  static 
machine  is  safer  for  the  patient.  I  use  the  static  machine  described  on  pages  9 
to  1 7  at  the  hospital,  and  a  static  machine  or  a  coil  at  my  office.  There  is,  I 
think,  an  advantage  in  using  the  larger  forms  of  apparatus  for  the  larger  new 
growths,  but  much  smaller  forms  will  answer  for  the  smaller  and  superficial 
growths,  although  the  time  of  exposure  and  the  distance  of  the  tube  should  not 
be  the  same  in  the  one  case  as  in  the  other.  .^11  forms  of  X-ray  apparatus  should 
have  adjustable  multiple  spark-gaps  (see  pages  16,  17,  and  26)  by  means  of  which 
the  light  may  be  regulated. 

1  Atlas  der  Radiograpkie  der  Briistorgane,  p.  75.     Emil  \V.  Engel,  Wien  u.  Leipzig. 


\ 


APPENDIX 


65: 


Resistance  of  Tithe.—  (See  pages  42  to  49.)  The  next  important  considera- 
tion is  the  choice  of  a  suitable  tube,  and  the  following  fact  throws  some  light  on 
the  subject.  Frida  Hansmann^  has  shown  that  the  rays  from  a  tube  of  low  resist- 
ance reduce  a  larger  amount  of  the  silver  salt  in  a  photographic  film  than  those 
from  a  tube  of  high  resistance,  that  is,  probably  more  rays  from  a  tube  of  the 
former  character  are  stopped  by  the  film  and  exert  their  action  there  than  from 
a  tube  of  the  latter  kind. 

This  suggests  that  tubes  of  low  resistance  should  be  used  for  treating  super- 
ficial lesions,  because  much  of  the  light  from  such  tubes  is  absorbed  in  or  near 
the  surface  ;  but  tubes  of  high  resistance  for  deep-seated  lesions,  as  the  light 
from  such  tubes  does  not  exert  so  large  a  proportion  of  its  action  upon  the 
surface. 

Tube  Holder.  —  The  tube  should  be  placed  in  a  tube  holder,  the  inside  of 
which  is  painted  with  many  coats  of  white  lead  as  suggested  by  Rollins  (see 
pages  50  and  400),  which  obstructs  the  passage  of  the  rays  so  that  they  can  find 
an  exit  only  where  special  provision  has  been  made  for  them.  The  X-rays  should 
never  be  used  without  enclosing  the  tube  in  some  form  of  the  Rollins  tube  holder. 

Figure  397  shows  the  coil,  stretcher,  and  tube  holder,  and  Fig.  398  the  tube 
holder  in  relation  to  the  patient  when  he  is  being  treated  in  a  prone  position. 
The  top  of  the  box  has  a  circular  opening  5  (better  10)  centimetres  in  diameter, 
that  is  covered  by  a  piece  of  plate  glass  15  millimetres  thick.  Through  this 
glass  and  the  opening  in  the  bottom  of  the  box  the  physician  can  look  down  and 
get  a  view  of  the  area  to  be  treated,  and  see  that  the  target  of  the  tube  is  in 
proper  relation  to  it.  After  the  tube  has  been  arranged  so  that  the  rays  will  fall 
on  the  diseased  part,  an  aluminum  screen  (0.25  mm.  thick)  is  slipped  in  to 
cover  this  lower  opening,  and  is  then  grounded.  This  grounded  screen  carries  off 
the  electricity  that  is  about  the  tube,  which  may  be  a  source  of  discomfort  to  the 
patient,  but  does  not  protect  from  the  action  of  the  X-rays.  There  is  also  an 
opening  in  the  back  that  is  covered  with  a  sheet  of  plate  glass,  and  another  in  the 
front  of  the  box,  so  that  when  the  patient  is  treated  in  a  sitting  position  the  phy- 
sician can  look  through  the  box  from  back  to  front  and  see  as  before  that  the 
target  is  in  the  exact  position  desired.  The  opening  in  the  box  next  the  patient, 
whether  he  is  treated  in  a  prone  or  in  a  sitting  position,  is  covered  by  an  iris- 
diaphragm,  which  limits  the  size  of  the  cone  of  rays  issuing  from  the  box  so  that 
it  covers  a  spot  a  litde  larger  than  the  diseased  area.  The  rays  are  limited 
exactly  to  the  area  desired  by  placing  over  it  a  sheet  of  pure  tin  or  lead  (or  a 
mask  may  be  used,  as  shown  on  page  400),  i  or  2  millimetres  thick,  which  has  an 
opening  in  it  corresponding  in  size  and  shape  to  the  area  to  be  treated.  As  the 
diseased  area  heals,  another  piece  of  the  sheet  metal  is  used  with  a  suitably 
smaller  opening. 

Method  of  Treatment.  —  Before  the  diseased  part  is  exposed  to  the  X-rays,  the 
patient  should  be  placed  in  a  comfortable  position.     In  cases  of  superficial  new 

1 "  Beziehungen  zwischen  der  chemischen  Wirkung  der  aus  einer  Rontgenrohre  austretenden 
Strahlung  zur  Wirkung  des  Lichtes  auf  dieselbe  Bromsilbergelatine,"  Fortschritte  a.  d.  Gd>.  der 
Roenigenstr.,  B.  V,  H.  2,  pp.  89-115. 


656     THE    ROENTGEN    RAYS    IN  MEDICINE   AND    SURGERY 


growths  the  tube,  enclosed  in  the  tube  holder,  should  be  brought  to  within  15  or 
20  centimetres  (6  or  8  inches)  of  the  part  ;  in  skin  diseases  the  distance  should 
be  greater. 

Time    of  Exposure:    General  Rule.  —  The  diseased  area  should  be  given 


Fig.  397.  Cut  showing  X-ray  apparatus  and  stn-tclirr  witli  tube  LjIlIli-  a'.j-v.  ;!.._i_:.cr.  To 
place  the  tube  holder  below  the  patient  the  inner  side  of  the  stretcher  must  be  lifted  up,  and  the  holder, 
which  is  supported  by  a  counterpoise,  may  then  be  slid  down  to  any  desired  height  above  the  floor. 


APPENDIX  5^- 

an  exposure  of  five  minutes  for  the  first  few  sittings,  and  this  time  may  be 
increased  to  ten,  m  larger  growths  to  fifteen,  minutes,  and  the  exposures  may 
be  given  two  or  three  times  a  week.  But,  as  stated  on  page  446,  the  time  of 
exposure,  the  frequency  of  the  exposures,  and  the  distance  of  the  tube  from  the 


Fig.  398.  Cut  showing  position  of  tube  in  relation  to  patient  when  he  is  treated  in  a  prone 
position.  The  sheet  tin  placed  over  the  face  to  protect  the  healthy  parts  from  the  X-rays  has  been 
pushed  forward  a  little  to  show  the  opening  in  it.  The  aluminum  screen  has  been  slipped  in  and 
grounded,  but  the  pliysician  is  represented  as  it  he  were  looking  through  tlie  box  to  ascertain  whether 
or  nut  the  target  is  in  the  proper  position  with  regard  to  the  diseased  area. 

patient    must    be    determined    for    each    individual,    each    disease,    and    each 
apparatus. 

Exposures  given  by  Phxsicians.  —  There  has  been  a  tendency  to  put  non- 
medical men  in  charge  of  X-ray  work,  but  these  rays  can  be  most  satis- 
factorily used  as  a  therapeutic  measure  under  the  immediate  charge  of  a 
physician  who  understands  how  to  use  the  apparatus,  or  better,  by  the  physician 
himself.     It  appears  to  be  a  simple  matter  in  a  hospital,  for  example,  to  send  a 


658     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

patient  to  the  non-medical  man,  who  has  charge  of  the  static  machine  or  the 
coil,  with  the  direction  that  the  diseased  area  be  exposed  to  the  X-rays  ;  but  this 
man  knows  nothing  of  the  medical  side  of  the  question,  and  can  only  succeed 
imperfectly  in  his  attempts  to  use  the  X-rays  as  a  remedy,  or  he  may  do  harm 
with  them.  These  rays  are  a  powerful  form  of  energy,  and  must  be  used  care- 
fully and  understandingly,  especially  when  employed  as  a  therapeutic  measure. 

X-RAY    DERMATITIS 

Kienbock^  describes  four  degrees  of  acute  X-ray  dermatitis.  The  first  degree 
appears,  as  a  rule,  twelve  to  sixteen  days  after  exposure,  but  sometimes  after  a 
longer  period.  The  hair  loosens  and  finally  falls  out,  leaving  the  skin  smooth  and 
bald,  but  without  any  other  abnormal  appearances  except  sometimes  marked 
pigmentation.  After  a  lapse  of  some  weeks,  generally  six  to  eight  weeks,  the 
skin  begins  to  become  normal  again  and  the  hair  to  grow.  Some  months,  per- 
haps three  to  four,  after  the  signs  of  injury  have  appeared  complete  return  to  the 
normal  condition  takes  place. 

In  cases  where  the  X-ray  exposure  has  been  more  intense.  X-ray  dermatitis 
in  the  second  degree  appears  and  after  a  somewhat  shorter  latent  period  than 
when  the  first  degree  occurs.  There  is  a  slight  general  swelling,  or  certain  areas 
only  may  be  swelled.  The  hyperasmia  is  first  of  a  light  red  color  and  later  of 
a  dark  red  color,  and  there  is  irritation.  These  acute  symptoms  last  a  few  days 
and  are  followed  first  by  complete  loss  of  hair,  later  by  an  increasing  pigmenta- 
tion of  the  skin,  and  finally  by  the  scaling  off  of  the  epidermis.  After  these 
scales  of  different  sizes  have  been  thrown  off,  the  epidermis  is  very  tender  and 
smooth,  of  a  delicate  color,  and  devoid  of  hair  for  some  weeks  ;  but  finally  the 
conditions  become  normal  again,  except  that  occasionally  a  little  hyperpigmenta- 
tion  remains. 

Blisters,  or  even  extensive  exfoliation,  occur  in  the  third  degree  of  X-ray 
dermatitis,  and  a  complete  recovery  does  not  take  place  as  a  rule,  the  hair 
does  not  grow  again,  or  only  scantily,  while  changes  in  pigmentation  and  patches 
of  telangiectasis  remain  permanently ;  there  is  atrophy  of  the  cutis  and  papillae 
with  sensitive  scars. 

The  fourth  and  most  severe  degree  of  X-ray  dermatitis,  which  consists  of 
superficial  dry  necrosis  of  the  tissue,  is  of  still  longer  duration.  After  a  latent 
period  of  from  one  to  two  weeks  the  skin  appears  brown,  sometimes  almost 
black,  and  an  ulcer  appears  which  may  heal  after  some  weeks  or  remain  torpid 
for  some  months  or  even  a  year.  These  conditions  may  not  be  accompanied 
by  pain. 

Chronic  X-Ray  Dermatitis.  —  Besides  the  above-mentioned  acute  kinds  of 
X-ray  dermatitis,  Kienbock  also  describes  a  chronic  kind,  the  result  of  many 
X-ray  exposures,  of  which  there  are  three  degrees. 

The  first  degree  is  distinguished  by  an  atrophy  of  the  hair  bulbs,  and  alopecia 

1 "  Hautveranderungen  durch  Roentgenbestrahlung  bei  Mensch  und  Thier,"  Wiener  Med. 
Presse,  1901,  pp.  874-879. 


APPENDIX  r 

\  659 

■;  and  atrophy  of  the  glands  of  the  skin.     This  change  can  be  permanent    and 
represents  the  ideal  result  of  a  hypertrichosis  treated  by  the  i  ravs 

In  the  second  degree  the  skin  becomes  thinner  and  slightfy  wrinkled  and 
t  ere  is  extensive  atrophy  of  the  skin;  it  may  develop  into  a  dystrophy  of  the 
sk.n,  a  th.cken.ng  o  the  epidermis,  and  be  accompanied  by  hyperpigmentation 
and  a  deepening  of  the  normal  markings  in  consequence  of  the  permanJ^i" 
relaxation  of  the  walls  ot  the  blood  vessels.  These  changes  occur  very  fre- 
,ncntly  on  the  outer  side  of  the  hands  of  people  who  are  engaged  in  nfaking 
\-ray  apparatus  and  tubes,  or  with  the  physical  study  of  the  X-rays  and  with 
thc.r  use  in  medicme.  Not  only  does  the  skin  on  the  back  of  the  hand  become 
thickened  and  of  a  brown  red  color,  but  there  are  also  fewer  hairs,  and  the  nails 
likewise  are  affected.  Further,  the  skin  is  very  easily  injured  mechanically  and 
shows  as  a  result  of  cold  a  marked  paralysis  of  the  vessels  (X-ray  skin) 

The  third  and  most  severe  degree  of  chronic  X-ray  injurv  consists  in  the 
destruction  of  portions  of  the  skin.  An  ulcer  gradually  forms  and  increases 
outward  and  downward,  but  does  not  go  beyond  the  part  exposed  to  the  X-rays 
This  injury  is  not,  as  a  rule,  the  result  of  individual  idiosyncrasy,  but  rather 
.itpends  upon  the  degree  of  over-exposure  to  the  X-rays.  It  should  not  be 
assumed  that  an  exposure  that  would  cause  a  passing  hypen-emia  in  one  person 
could  produce  an  ulcer  in  another.  Nevertheless,  individuals  differ  in  their  sus- 
,ceptibility  to  the  X-rays,  children  and  especially  delicate  persons  reacting  more 
intensely  than  adults  and  vigorous  people.  Likewise,  the  skin  of  certain  parts 
of  the  body  is  more  susceptible  than  that  of  other  parts. 

Further  Kienbock  states  that  when  a  considerable  inflammation  or  chronic 
change  has  been  produced  in  the  skin,  it  reacts  more  quickly  to  later  exposures  for 
a  long  period  of  time. 

Causes  of  Changes  in  the  Skin.  —  Kienbock  '  believes  that  the  effects  produced 
•on  the  skin  by  the  X-rays  are  due  to  a  chemical  change  in  the  tissues  caused  by 
jthat  portion  of  the  X-rays  that  is  absorbed,  and  that  the  processes  of  disintegra- 
ition  which  presumably  take  place  in  the  skin  after  its  exposure  to  the  X-rays  are  of 
la  peculiar  kind.  No  outward  visible  changes,  as  is  known,  are  seen  on  the  skin  at 
first,  but  an  inflammation  may  appear  after  an  interval  which  may  increase  for 
'some  days  or  weeks,  or  even  for  a  longer  period.  This  inflammation  may  be 
•accompanied  by  headache,  restless  sleep,  a  temperature  of  38°  to  40°,  etc. 
These  symptoms  can  be  explained  by  the  idea  that  toxines  are  formed  in  the 
tissues  of  the  injured  skin,  and  that  a  general  intoxication  of  the  organism  takes 
Iplace  by  the  absorption  of  the  same  into  the  circulation. 

'  Kienbock  believes  that  X-ray  dermatitis  is  caused  by  the  reaction  of  the 
tissue  cells,  even  those  in  the  deepest  layer  of  the  skin,  to  the  disturbance  pro- 
duced in  the  metabolism  by  the  X-rays  that  are  absorbed.  The  assumption  that 
|the  injury  to  cell  activity  caused  by  the  X-rays  may  be  temporary  or  permanent 
agrees  with  the  facts  observed  ;  namely,  that  animals  endowed  with  a  more  lively 
'metabolism  —  the  warm-blooded  animals  —  are  more  markedly  influenced  than 

^  ]Viener  Med.  Presse,  Vol.  42,  1901,  pp.  1039-1040.     See  also  pp.  932-937  and  9S7-989. 


66o     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

the  cold-blooded  ones  ;  that  young  animals  react  more  quickly  and  more  violently 
to  the  X-rays  than  adults,  and  these  latter  more  quickly  than  old  ones  ;  further, 
that  that  organ  especially  suffers  pathological  changes  that  in  proportion  to  its 
continuous  cell  proliferation  possesses  the  most  active  metabolism,  —  for  instance, 
the  skin,  the  papilla;  of  the  hair,  especially  the  hair  of  the  head  and  beard. 

Kienbock  states  that  the  attempt  to  explain  the  pathogenesis  of  X-ray  der- 
matitis, and  the  following  trophic  disturbances,  by  the  supposition  of  a  disturbance 
of  cell  activity  through  a  formation  of  toxines  is  in  harmony  with  the  idea 
that  chemical  changes  in  the  tissues  follow  exposure  to  the  X-rays,  and  it 
also  explains  the  surprisingly  long  latent  period  and  the  temporary  general  in- 
toxication of  the  body  after  exposure  to  the  rays.  Kienbock  believes,  however, 
that  the  question  demands  further  investigation,  especially  in  the  direction  of 
chemistry  and  by  means  of  experiments. 

Frequency  of  Burns.  —  Dr.  E.  A.  Codman  ^  has  collected  171  cases  of  X-ray 
burns,  and  he  concludes  from  a  careful  study  of  them  that  the  frequency  of  X-ray 
injuries  has  been  much  exaggerated  ;  that  at  a  maximum  estimate  it  is  safe  to 
say  that  not  one  patient  in  five  thousand  has  been  injured  in  the  past  five  years 
by  an  X-ray  examination,  and  in  the  past  year  not  one  in  ten  thousand ;  that  the 
important  factors  in  the  production  of  an  X-ray  burn  are  the  intensity  of  the 
current  used  to  excite  the  tube,  the  quality  of  the  tube,  the  distance  and  time  of 
exposure,  and  the  idiosyncrasy  of  the  patient.  Codman  thinks  that  the  latter  is 
a  very  important  element  in  the  problem,  that  much  depends  upon  the  dryness  or 
dampness  of  the  skin  of  the  patient,  on  his  electrical  resistance,  upon  his  being 
in  an  anaemic  or  plethoric  condition,  etc. 

In  one-third  of  the  reported  cases  injury  took  place  within  the  first  four  days;, 
in  one-half  before  the  ninth  day ;  and  it  became  visible  from  a  few  minutes  to 
three  weeks  after  exposure,  but  in  two  cases  five  months  after  exposure.  Codman| 
believes  that  the  reason  such  a  large  proportion  of  the  severe  burns  occur  in  the. 
abdomen  and  groin  is  due  to  the  fact  that  these  parts  require  the  longest  expos-; 
ures,  because  they  are  the  thickest  portions  of  the  body.  The  data  of  the  reported' 
cases  show  that  no  burn  has  been  produced  by  an  exposure  of  five  minutes  with 
the  tube  at  a  distance  of  25  centimetres. 

Since  this  excellent  article  by  Codman  was  published,  the  X-rays  have  been 
in  much  more  frequent  use  for  therapeutic  purposes  and  therefore  the  opportuni- 
ties for  burns  have  increased  and  I  believe  many  have  occurred.  The  precautions, 
that  should  be  taken  to  avoid  them  are  described  on  pages  642  and  655.  When' 
the  X-rays  are  used  for  therapeutic  purposes,  it  may  be  justifiable  to  push  the  ex- 
posures intentionally  up  to  the  point  of  causing  a  mild  form  of  burn,  but  the} 
should  not  be  allowed  to  occur  through  lack  of  care,  or  knowledge  of  proper  pre- 
cautions. Except  for  two  instances  where  mild  forms  of  burns  were  intentionall\ 
produced,  I  have  seen  none  in  more  than  twelve  thousand  exposures. 

^  "  A  Study  of  the  Cases  of  Accidental  X-Ray  Burns  hitherto  Recorded,''  Philaddphu 
Medical  Journal,  March  8,  1902. 


APPENDIX  66 1 


TREATMENT    FOR   X-RAY    BURNS 

Bar  and  Boulle  ^  describe  at  some  length  the  following  case  of  X-ray  burn, 
for  the  cure  of  which  the  red  rays  were  used  :  — 

This  patient,  a  pregnant  woman  twenty-three  years  of  age,  who  had  always  been 
bealthy,  entered  the  Infirmary  of  Saint  Lazare  on  account  of  blenorrhagia,  ac- 
:ompanied  by  abdominal  pains.  On  September  7,  when  she  had  been  pregnant 
ibout  three  months,  the  X-rays  were  applied  for  the  purpose  of  producing  a 
blister.  The  patient  complained  of  no  special  sensation  during  the  exposure,  and 
the  skin  remained  white.  September  25,  eighteen  days  after  the  sitting,  an  erythema 
appeared  on  the  abdominal  wall,  but  there  was  no  loss  of  hair  and  no  irritation. 
The  slight  erythema  increased,  however,  and  was  followed  by  irritation,  but  there 
was  no  erosion.  Later  an  erosion  developed  in  the  left  groin,  but  this  healed, 
only  a  marked  irritation  remaining.  Two  months  after  the  exposure  an  acute 
attack  of  dermatitis  appeared  and  was  followed  by  a  deep  and  extensive  ulcer- 
ation which  increased  in  size  and  depth.  Gradually  the  tissues  in  the  centre  of 
the  ulcerated  area  became  gangrenous  and  sloughed  off,  but  the  ulceration  showed 
no  tendency  to  heal. 

At  this  time  the  patient  was  sent  to  the  maternity  hospital.  She  had  been 
pregnant  about  six  and  a  half  months.  i\bove  the  left  groin  there  was  a  deep 
ulcerated  area  as  large  as  the  palm  of  the  hand,  the  centre  of  which  was  gan- 
grenous. The  usual  treatment  was  employed,  but  in  spite  of  it  the  ulceration 
increased,  and  became  so  deep  that  a  perforation  of  the  abdominal  wall  was 
feared.  This  condition  obtained  on  January  15,  1901,  —  that  is,  four  months 
after  the  application  of  the  X-rays. 

On  February  3  twins  were  born.  There  was  some  fever  following  the  birth 
of  the  children,  during  which  time  the  ulceration  in  the  abdominal  wall  remained 
without  change,  but  a  fortnight  later  it  began  suddenly  to  deepen,  and  at  the 
same  time,  February  20,  a  crust  appeared  on  the  abdominal  wall  to  the  right  of 
the  umbilicus,  in  a  place  where  the  pigmentation  had  been  very  marked.  This 
crust  increased  in  size  and  depth.  It  was  situated  at  a  point  where  some  days 
before  a  hypodermic  injection  of  salt  solution  had  been  given.  March  12,  six 
months  after  the  application  of  the  X-rays  and  forty  days  after  the  birth  of  the 
children,  the  ulceration  in  the  groin  was  extensive,  and  in  the  umbilical  region 
the  ulceration  had  a  crust  detached  from  the  skin,  but  adherent  below. 

The  various  treatments  employed  to  cure  these  ulcerations  were  ineffectual, 
and,  finally,  March  12,  Bar  and  Boull^  had  the  patient  carried  every  day  into  a 
sunny  corridor  and  placed  in  such  a  way  as  to  subject  the  abdominal  wall  to  the 
rays  of  the  sun  sent  through  red  glass.  Over  the  ulcerations  they  placed  a  trans- 
parent sheet  of  celluloid.  At  night  the  ulcerations  were  covered  by  an  inert 
powder.     Gradually  the  crust  produced  by  the  X-rays  sloughed  off,  and  at  the  end 

1  "  Ulcerations  profondes  et  troubles  trophiques  graves  de  la  parol  abdominale  produits  par 
les  rayons  X  chez  una  femme  enceinte  ;  heureuse  influence  des  rayons  rouges,"  Bulletin  Jc  la 
Sociite  cV  Obstctrique  de  Paris,  1901,  Vol.  IV,  pp.  251-266. 


662      THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

of  March  the  bottom  of  the  ulceration  was  clean ;  little  by  little  also,  at  first  very 
slowly,  the  ulceration  decreased  in  size,  and  May  5,  fifty  days  after  this  treat- 
ment was  begun,  the  healing,  hastened  by  cauterization  with  nitrate  of  silver,  was 
complete.  Likewise,  the  crust  situated  at  the  point  of  the  injection  of  salt  solu- 
tion detached  itself  and  showed  that  the  tissues  underneath  were  gangrenous  over 
a  large  area.  The  gangrenous  tissue  having  sloughed  off,  a  sinus  so  deep  was 
left  that  it  was  necessary  to  make  an  incision  of  22  centimetres  in  order  to  lay 
bare  its  walls. 

The  general  health  of  the  patient,  which  up  to  that  time  was  precarious,  then 
improved  quickly.  On  May  5,  in  place  of  the  large  ulceration  above  the  pubes, 
there  was  a  firm  scar  much  smaller  than  the  ulceration,  and  in  place  of  the  one 
near  the  umbilicus  there  was  a  long,  narrow  scar  left  by  the  operation  done  to 
open  the  cavity. 

Bar  and  Boulle  do  not  affirm  that  the  red  rays  were  the  efficient  agent  in 
curing  the  ulcerations,  but  say  that  the  cure  may  have  been  due  to  the  recovery 
of  the  patient  from  the  birth  of  the  children,  and  likewise  that  perhaps  the  sub- 
jection of  the  patient  to  intense  sunlight  had  a  favorable  effect  on  the  general 
system  and  indirectly  increased  the  vitality  of  the  tissues,  but  think  that  their 
experience  authorizes  the  use  of  colored  rays,  and  preferably  perhaps  red  rays  in 
cases  that  resist  all  other  treatment. 

Bouchacourt  thinks  the  success  obtained  by  Bar  and  Boulle  was  due  in  part 
to  the  caloric  power  of  the  red  rays  and  in  part  to  their  lack  of  chemical  prop- 
erties. He  states  that  darkness  and  red  light  have  been  used  indifferently  and 
with  identical  results  in  the  treatment  of  smallpox  ;  that  Flammarion  experi- 
mented with  sensitive  plants,  strawberry  plants,  etc.,  and  found  that  they  grew 
extraordinarily  under  red  glass  ;  at  the  end  of  three  months  the  sensitive  plants 
were  fifteen  times  taller  than  those  growing  under  blue  glass  ;  he  also  observed 
that  the  plants  grown  under  red  glass  had  more  fragrance  than  those  grown  under 
other  colors.  The  results  were  the  same  if  the  plants  were  grown  under  red  glass 
or  in  the  dark,  other  conditions,  such  as  heat,  moisture,  and  air,  being  the  same, 
except  that  the  chlorophyl  which  gives  the  leaves  their  green  color  was  entirely 
lacking. 

Bouchacourt  also  states  that  the  ex])eriments  made  by  Finsen,  Schenk,  and 
Graber  on  animals  that  dislike  the  light,  like  salamanders,  earwigs,  tadpoles,  etc., 
and  on  those  that  love  the  light,  like  butterflies,  show  that  the  former  prefer  the 
red  rays  and  the  latter  the  chemical  blue  rays.  These  experiments  and  later 
ones  demonstrate  that  white  light  is  a  stimulating  agent  of  considerable  power, 
its  action  being  due  almost  wholly  to  the  chemical  rays,  and  that  therefore  the 
use  of  the  red  rays  by  Bar  and  Boulle  was  a  legitimate  one.    . 

Hyde,  Montgomery,  and  Ormsby  ^  also  discuss  the  action  of  light  on  animals 
as  determined  by  the  experiments  of  Graber,  Bert,  Lubbock,  and  others,  but  more 
particularly  by  the  researches  of  Jaques  Loeb,  and  state  that  his  observations  show 
that  blue  and  violet  light  stimulate  directly  the  animal  cells,  the  stimulus  result- 

^  "  A  Contribution  to  the  Subject  of  Radiotherapy  and  Phototherapy  in  Carcinoma,  Tuber- 
culosis, and  Other  Diseases  of  the  Sk'm,"  Journal  0/  A?n.  Med.  Assn.,  January  3,  1903,  pp.  1-8. 


APPENDIX 


663 


ing,  probably,  from  chemical  changes.  They  also  state  that  Benedict  Friedlander 
demonstrated  by  control  experiments  that  dermatitis  and  pigmentation,  followino' 
exposure  of  the  skin  to  sunlight  or  to  strong  electric  light,  are  caused  by  the  blue 
and  violet  rays,  and  not  by  the  heat  rays. 

THE   X-RAYS    AS   AN   ANALGESIC 

Various  practitioners  have  reported  cases  in  which  pain  has  been  relieved, 
besides  those  cases  of  new  growth  in  which  intense  suffering  has  been  removed 
that  will  be  referred  to  later,  which  justify  us  in  believing  that  the  X-rays  have 
some  special  action  upon  the  nerves.  They  give  relief  from  pain  in  some  cases 
in  various  affections,  such  as  facial  and  intercostal  neuralgia,  lumbago,  hepatic  colic, 
fracture,  and  in  some  forms  of  herpes.     The  following  cases  are  illustrative. 

Freund^  states  that  Grunmach  (1899)  has  used  X-rays  in  cases  of  neuralgia 
of  the  face,  of  the  back,  of  the  head,  of  the  intercostal  nerves,  and  in  rheuma- 
tism of  the  joints  and  muscles,  with  variable  results;  that  Stembo  (1900)  cured 
21  out  of  28  cases  of  neuralgia  in  3  to  10  sittings  of  3  to  10  minutes'  duration 
by  the  use  of  the  X-rays.  Freund  himself  reports  the  case  of  an  old  man  who  had 
such  a  severe  trigeminal  neuralgia  that  it  could  scarcely  be  helped  by  morphine, 
but  which  he  treated  by  the  X-rays  and  so  brought  about  a  wonderful  diminution 
in  the  pain  after  1 1  exposures.     In  a  second  case  the  X-rays  had  no  effect. 

Dr.  E.  D.  Bondurant-  has  known  one  application  of  the  X-rays  to  stop  facial 
neuralgia,  and  to  remove  intense  intercostal  neuralgic  pain. 

L^r.  Seabury  VV.  Allen  '■"'  reports  several  cases  in  which  the  X-rays  acted  as 
an  analgesic.  One  w^as  that  of  a  woman  whose  hands  were  radiographed  for  the 
purpose  of  making  a  diagnosis  of  chronic  rheumatic  arthritis.  F"ive  days  later  the 
patient  reported  that  since  the  X-ray  photographs  were  taken  her  hands  had 
been  comfortable,  and  she  had  been  able  to  resume  the  use  of  the  piano. 

A  second  case  was  that  of  a  woman  who  had  a  discharging  sinus  of  the  shoul- 
der, of  eight  months'  duration,  that  followed  an  operation  for  the  removal  of  frag- 
ments of  bones.  An  X-ray  photograph  was  taken  preparatory  to  operation  for 
diagnostic  purposes,  but  the  operation  was  abandoned,  as  the  patient  several  days 
later  said  that  the  motion  of  the  joint  was  freer  and  that  it  felt  comfortable. 

A  third  case  was  that  of  a  man  whose  ankle  was  radiographed  to  confirm  the 
diagnosis  of  Pott's  fracture.  Forty-eight  hours  later  his  wife  came  for  the  nega- 
tives, and  at  that  time  expressed  a  disbelief  in  the  existence  of  the  fracture 
because  the  ankle  felt  so  much  better. 

In  a  fourth  case,  varicose  ulcers  of  the  legs,  the  pain  was  relieved  not  only  m 
the  ulcerated  area,  but  also  in  the  hip  joint,  although  only  the  lower  leg  was  ex- 
posed :  and  in  a  fifth  case  improvement  took  place  in  the  shoulders,  although  only 

1  "  Grundriss  der  Gesammten  Radiotherapie  fiir  Praktische  Aerzte,"  1903,  P-  244- 

2  "  Some  of  the  Therapeutic  Uses  of  the  X-Ray,"  Neiu  York  Medical  Journal,  August, 
1902,  Vol.  Ixxvi,  pp.  194-196. 

3  "Notes  on  the  Analgesic  Effects  of  the  X-Rays,"  American  Medicine,  March  22,  1902, 

p.  461. 


664     'fHE   ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

the  sides  of  the  neck  were  exposed.  Dr.  Allen  suggests  that  the  nerve  supply  of 
the  parts  in  question  may  account  for  these  facts,  although  nothing  can  be  proved 
by  two  cases ;  in  the  first  case  branches  of  the  same  nerve  that  supplies  the  por- 
tion of  the  skin  that  was  exposed  to  the  X-rays  also  supply  the  hip  joint ;  in  the 
second  case  the  branchial  plexus  that  was  exposed  to  the  X-rays  also  supplies  the 
shoulder  muscles. 

Analgesia  did  not  immediately  follow  the  application  of  the  rays  in  any  of  the 
cases  reported  by  Dr.  Allen,  but  in  each  instance  did  take  place  within  forty-eight 
hours. 

Dr.  William  M.  Sweet'  of  Philadelphia  has  noted  the  pronounced  action  of  the 
X-rays  on  the  nerve  structures  as  seen  in  the  loss  of  sensation  of  healthy  skin 
after  too  long  or  too  frequent  exposures,  and  has  observed  that  large  portions  of 
the  cancerous  tissue  may  be  excised  without  pain  after  it  has  been  subjected  to 
the  X-rays  for  several  minutes. 

THE  X-RAYS  IN  THE  TREATMENT  OF   DISEASES   OF  THE   SKIN 

For  more  than  three  years  I  have  used  the  X-rays  in  the  treatment  of  some 
diseases  of  the  skin  and  have  become  more  and  more  convinced  of  their  value  in 
this  direction.  It  occurred  to  me  when  endeavoring  to  find  some  effective  way 
of  arousing  the  interest  of  the  profession  in  this  subject,  to  look  over  the  list  of 
diseases  that  Were  treated  in  the  skin  department  of  a  large  hospital  for  the  pur- 
pose of  ascertaining  how  large  a  proportion  of  them  could  be  relieved  by  the  use 
of  the  X-rays.  I  append  in  tabular  form  a  summary  made  from  the  report  of  the 
dermatological  department  of  the  Boston  City  Hospital  for  a  recent  year. 

In  343  out  of  the  1303  cases  the  X-rays  are  not  needed  ;  in  492  cases  they 
would  have  been  of  much  assistance  ;  in  some  of  the  372  cases  they  could  render 
help. 

These  figures  are  sufficient  to  suggest,  without  entering  into  a  detailed  con- 
sideration of  all  diseases  of  the  skin,  that  there  is  probably  no  single  remedy  which 
can  do  so  much  for  those  suffering  from  these  diseases  as  the  X-rays. 

1 "  The  Treatment  of  Epithelioma  of  the  Eyelids  by  the  X-Rays,"  Aiiiericati  Medicine,  De- 
cember 13,  1902,  pp.  935-937. 


APPENDIX 


66  = 


TABLE    OF    SKIN    DISEASES   TREATED   AT   THE   BOSTON   CITY    HOS- 
PITAL,  BUT   NOT    BY    THE   X-RAYS,    DURING    A    RECENT    YEAR 


Whole  number  of  cases  treated       ...... 

From  this  number  may  be  subtracted  certain  diseases  for  which 
there   are  good  remedies  — 
Pediculi 
Scabies 
Syphilis 

Dermatitis  (various  forms) 
Varicella     . 
Total  . 

Amono;  tlie  diseases  in  which   the  X-rays   are   of  value   may   be 
included  — 
Eczema 
Psoriasis  ^  . 
Acne 
Rosacea 
Epithelioma 
Hypertrichosis 
Keratosis    . 
Verruca 
Lupus 

Total  . 

The  X-rays   have   been    found   of  use  in  some  of  the   following 
diseases  — 
Prurigo 
Pruritus 
Seborrhea 
Tinea  fav.. 
Urticaria 
Hyperidrosis 
Impetigo 
Pityriasis 
Lichen 
Alopecia 
Herpes 
Herpes  zoster 
Total  . 


There  remain  — 
Erysipelas 
Furunculus 
Total  . 
Miscellaneous 
Total  . 


circin.,  syco.,  tons.,  versic 


75 

62 

no 


308 

35 
106 

17 
6 
I 
8 
6 
5 


7 
37 
65 
44 
10 

143 

8 

I 

20 

•5 


17 
12 


67 


1303 


343 


960 


492 


372 


29 
67 


960 


^Th 
given  wou 


proportion  of  individuals  suffering  from  this  disease  is  probably  larger  than  the  figure 
!d  indicate,  as  many  would  cease  attendance  when  they  found  relief  ditticult  to  obtam. 


666      THE    ROKXTGEX    RAYS    IX    MEDICIXE    AXD    SURCiERY 

DISEASES  OF  THE  SKIN  TREATED  BY  THE   X-RAYS 
I.  INFLAMMATIOXS 

Intertrigo 

Good  results  have  been  reported  as  following  the  use  of  tlie  X-rays  in  this 

disease. 

Herpes  Zoster 

I  have  used  the  X-rays  for  two  patients  suffering  from  shingles,  and  in  each 
case  some  reUef  was  obtained.  In  the  first  case,  temporary  relief  followed  two 
exposures,  given  on  two  successive  days ;  the  treatment  was  then  discontinued, 
as  the  patient  was  obliged  to  go  away.  In  the  second  case,  immediate  relief 
from  the  burning  sensation  and  pain  followed  the  first  exposure  ;  the  treatment 
was  then  suspended  for  a  time,  during  which  there  was  much  pain  in  the  side  of 
the  chest  in  which  the  eruption  occurred.  At  the  end  of  two  weeks  the  exposures 
were  resumed  and  given  three  times  a  week.  The  pain  ceased,  as  before,  after 
the  first  exposure  and  did  not  return. 

Psoriasis 

The  results  obtained  from  the  use  of  X-rays  in  psoriasis  are  more  satisfactory 
than  from  any  other  remedy  we  have  for  this  disease.  So  far  as  my  experience 
goes  all  cases  of  psoriasis  are  relieved  by  the  X-rays,  but  some  of  them  more 
promptly  than  others.  In  cases  that  are  acute,  that  is  to  say  where  the  color  is 
bright,  the  response  is  more  prompt. 

X-Ray  Exposures.  —  The  exposures  may  be  given  daily,  or  more  safely  three 
times  a  \veek.  The  number  necessary  to  bring  about  healing  in  any  given  area 
may  be  6  to  lo.  Therefore  if  there  are  many  widely  distributed  areas,  some 
time  would  be  required  to  make  the  number  of  exposures  necessary  to  treat  the 
whole  diseased  tract,  so  that  the  treatment  might  extend  over  many  weeks,  or  in 
a  case  of  long  standing  and  of  especially  obstinate  character,  over  a  number  of 
months. 

When  the  disease  covers  very  large  areas,  for  example,  the  whole  of  the  trunk, 
the  entire  front  or  back  may  be  exposed  at  once  by  placing  the  tube  at  a  dis- 
tance of  40  to  50  centimetres  from  the  body,  if  the  apparatus  is  sufficiently 
powerful.  If  the  apparatus  is  small,  the  tube  must  be  placed  nearer  the  patient 
and  therefore  only  a  comparatively  small  area  can  be  exposed  at  one  time,  then 
the  tube  must  be  moved  and  another  area  treated  ;  consequently  with  such  an 
apparatus  a  long  time  must  be  consumed  at  one  sitting  in  going  over  the  whole 
affected  tract,  area  by  area,  or  else  the  patient  must  be  under  treatment  for  a  long 
period. 

My  experience  has  been  that  under  the  most  favorable  conditions  improve- 
ment may  begin,  in  a  given  area,  within  three  days  after  a  single  exposure  of  ten 
minutes,  and  progress  rapidly  under  exposures  of  3  to  5  minutes'  duration,  given 
every  other  day,  the  tube  being  at  a  distance  of  20  centimetres. 


APPENDIX 


667 


Some  patients  do  not  show  improvement  so  rapidly  as  those  referred  to  above, 
but  after  a  very  few  exposures  improvement  is  readily  perceived,  even  in  the  worst 
cases. 

If  the  treatment  is  pursued  with  care  the  skin  heals,  becomes  natural,  soft, 
and  of  a  normal  color  without  any  irritation  being  caused  in  the  diseased  parts 
or  in  the  healthy  skin. 

Recurrences.  —  Recurrences  have  been  unusual  in  my  experience,  and  are  less 
likely,  I  believe,  to  occur  if  the  treatment  is  thorough  ;  but  if  they  take  place, 
they  yield  more  readily  to  treatment  than  the  first  attack.  Healing  seems  to 
begin  in  the  deeper  portions,  and  if  the  treatment  is  carried  out  so  thoroughlv  as 


Fig.  399.  A.B.  Psoriasisof  forty  years' duration.  When  this  patient  came  to  li..  :,.  :...a]iient  by 
the  X-ravs,  nearly  the  whole  of  the  front,  back,  and  sides  of  the  body  was  affected.  The  umbilicus 
is  seen  near  the  lower  right-hand  corner  of  the  cut.  The  upper  half  of  the  cut  sliows  the  rough,  dry 
scaly  psoriasis  before  treatment  by  the  X-  rays ;  the  lower  part  an  area  which  had  been  of  the  same 
character,  but  which  became  soft,  smooth,  and  almost  like  the  normal  skin,  except  in  color,  after  five 
exposures  to  the  X-rays  of  twenty  minutes  each.     After  some  months'  treatment  this  patient  recovered. 

to  remove  all  traces  of  the  disease,  and  then,  if  a  few  additional  exposures  are 
given  after  healing  has  apparently  taken  place,  recurrences  do  not  seem  to  occur 
within  a  few  months  at  least.  How  permanent  the  good  effects  of  the  X-rays 
mav  be.  it  is,  as  yet,  too  earlv  to  state. 

'Two  of  my  cases  illustrate  the  difference  with  which  patients  with  psoriasis 
yield  to  treatment  by  the  X-ravs.  In  one  case  (see  Fig.  399)  the  disease  was  of 
forty  vears'  standing,  in  the  other  of  thirty-eight  years'  duration  ;  in  both  cases  it  was 


668     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

distributed  over  most  of  the  trunk  and  large  portions  of  the  extremities.  In  the 
first  case,  signs  of  improvement  were  seen  after  five  exposures,  and  the  treat- 
ment was  continued  for  months  ;  in  the  second  case,  improvement  showed  itself 
after  two  exposures,  and  the  treatment  was  continued  for  weeks  only. 

The  patient  who  yielded  more  readily  had  the  advantage  of  a  much  more 
powerful  apparatus  during  the  whole  of  the  treatment,  so  that  the  tube  could  be 
placed  at  such  a  distance  from  his  body  as  to  expose  the  whole  side  of  it  at 
once ;  whereas  the  other  had  a  small  apparatus  in  the  beginning  of  the 
exposures ;  but  I  do  not  think  the  difference  in  apparatus  accounted  altogether 
for  the  difference  in  the  time  required  to  produce  healing. 

It  has  been  stated  that  it  might  be  a  disadvantage  to  the  patient  to  expose 
large  areas  at  one  time  ;  but,  so  far  as  I  have  observed,  there  is  nothing  but 
advantage  in  so  doing.  The  improvement  of  the  patient  under  such  circum- 
stances is  much  more  rapid. 

It  would  seem  as  if  the  X-rays  had  a  tonic  effect  upon  the  patient,  aside  from 
the  improvement  due  to  the  relief  obtained.  One  of  my  patients  was  much, 
gratified  to  find  that  he  felt  better,  and  the  muscular  stiffness,  which  in  old  age 
is  apt  to  follow  prolonged  exercise,  was  not  so  apparent  after  he  had  been  under 
treatment  for  some  weeks  ;  he  frequently  spoke  of  what  I  may  call  the  rejuvenat- 
ing action  of  the  rays.  The  sittings  in  his  case  were  sometimes  of  two  hours' 
duration  in  order  that  the  whole  diseased  area  might  be  given  its  due  proportion 
of  treatment.  I  have  had  other  patients  also,  one  a  nervous  invalid,  in  which 
similar  tonic  effects  have  followed  exposure  to  the  X-rays  —  the  treatment  in 
these  latter  cases  was  given  for  this  purpose. 

Dr.  Startin  ^  reports  a  case  of  psoriasis  that  came  under  his  care  in  March, 
1900.  The  patient  was  a  woman  twenty-one  years  of  age,  who  had  psoriasis  of 
the  legs,  arms,  and  body.  Dr.  Startin  first  treated  her  with  tonics,  arsenic,  and 
tarry  preparations,  until  she  was  tolerably  well,  except  for  one  patch  on  the  leg 
about  6  inches  long  and  3  inches  wide.  This  patch  he  treated  with  the  X-rays, 
giving  the  patient  seven  exposures  at  intervals  of  about  three  days,  with  the 
result  that  the  whole  skin  was  healthy  about  a  fortnight  after  the  last  sitting. 
Dr.  Startin  states  that  in  the  treatment  of  skin  diseases  he  generally  gives  four 
or  five  exposures  of  10  to  15  minutes  on  consecutive  days,  with  the  target  at 
a  distance  of  5  inches. 

Hahn  -  reports  that  this  disease  is  favorably  influenced  by  the  X-rays.  The 
scales  fall  off  after  the  first  four  to  six  treatments  without  the  bleeding  charac- 
teristic of  patches  of  psoriasis  appearing.  The  cases  had  not  been  under 
observation  long  enough  to  say  whether  or  not  there  would  be  a  recurrence. 

Drs.  Hyde,  Montgomery,  and  Ormsby''  have  treated  thirty- two  cases  of 
psoriasis  by  means  of  the  X-rays,  and  in  each  case  the  results  were,  at  least, 

1  "  On  X-Rays  in  the  Treatment  of  Rodent  Ulcer,"  The  Lancet,  July  20,  1901,  pp.  144-145. 

2  Fortschritte  a.  d.  Geb.  der  Roentgenstr.,  B.  IV,  H.  2,  pp.  95-96. 

*  "  A  Contribution  to  the  Subject  of  Radiotherapy  and  Phototherapy  in  Carcinoma,  Tuber- 
culosis, and  Other  Diseases  of  the  Skin,"  Journal  American  Medical  Association,  January  3, 
1903.  PP-  1-8. 


APPENDIX 


669 


temporarily  satisfactory.  Four  to  ten  short  exposures  of  a  given  place  (length 
of  exposure  not  given),  with  the  tube  at  a  distance  of  about  25  to  30  centi- 
metres, were  usually  enough  to  cause  the  trouble  to  disappear  except  for  a  certain 
amount  of  pigment.  In  cases  where  the  thickening  was  moderate  the  scales 
often  disappeared  after  the  second  or  third  treatment,  and  the  itching,  if  any  was 
present,  was  relieved  at  about  the  same  time.  The  writers  noticed  that  as  a  rule 
the  first  effects  produced  from  exposure  to  the  X-rays  were  the  inability  to  show 
bleeding  points  and  the  reduced  number  of  scales,  and  that  the  latter  became 
more  easily  detached,  lost  their  micaceous  appearance,  and  were  more  friable  or 
even  powdery.  In  about  fifty  per  cent  of  the  cases  the  psoriasis  appeared  again 
within  a  few  weeks,  either  in  the  old  or  in  new  parts.  In  the  remaining  cases  re- 
currence did  not  occur  for  several  months.  In  two  cases  of  circumscribed  areas 
of  psoriasis,  which  wfere  of  many  years'  duration,  ten  exposures  to  the  X-rays 
were  given,  and  no  recurrence  had  taken  place  in  eight  months ;  but  in  a  few  of 
the  widely  distributed  cases,  although  the  treatment  was  carried  out  for  several 
weeks,  a  recurrence  took  place  while  new  regions  were  being  treated ;  as  a  rule, 
however,  the  recurrent  patches  disappeared  more  quickly  under  treatment  than 
did  the  original  ones.  The  writers  also  found  that  the  cases  of  short  duration 
were  more  easily  dealt  with  than  those  of  long  standing.  In  one  very  acute  case, 
in  which  the  skin  of  the  patient  was  especially  sensitive,  exposure  to  the  X-rays 
seemed  to  render  tlie  skin  more  irritable. 

They  likewise  state  that  the  influence  of  the  X-rays  in  psoriasis  is  in  harmony 
with  the  fact  demonstrated  by  Hyde,  twelve  years  ago,  and  often  since,  that  some 
cases  can  be  cured  by  exposing  the  skin  to  the  sun. 

ECZEINIA 

So  far  as  I  can  iudge  from  the  use  of  the  X-rays  in  this  disease  for  more  than 
two  years,  all  forms  of  eczema,  acute,  chronic,  moist,  and  dry,  seem  to  be  amena- 
ble to  treatment  by  them.  In  the  case  described  on  page  410  there  proved 
to  be  some  doubt  about  the  diagnosis.  The  relief  from  the  painful  symptoms  in 
acute  cases  with  much  swelling,  irritation,  and  sensation  of  heat  sometimes  takes 
place  within  a  few  hours  after  exposure  to  the  X-rays.  In  cases  of  moist  eczema, 
accompanied  by  a  good  deal  of  pain  and  much  fetid  discharge  over  an  almost 
raw  surface,  relief  from  discomfort  may  be  obtained  within  a  few  days.  Patients 
who  at  first  are  afraid  to  give  up  the  local  treatment  they  have  been  using  soon 
rejoice  in  being  relieved  from  it.  But  while  relief  may  be  had  from  the  use 
of  the  X-rays  in  certainly  most  cases  of  eczema  within  a  short  time,  the  healing  of 
the  skin  may  require  some  weeks. 

While  it  is  too  earlv  to  state  that  the  X-rays  will  cause  healing  in  all  cases  of 
eczema,  there  is  no  question  they  afford  us  a  means  of  giving  relief  in  this  com- 
mon and  hitherto  obstinate  form  of  skin  disease.  Some  of  my  patients  have  been 
children  who  were  worn  out  with  constant  scratching  and  sleeplessness ;  others 
were  women  with  eczema  of  the  face,  to  whom  the  disease  was  not  only  a  dis- 
comfort, but  a  distress;  still  others  were  men  of  middle  age  who  had  suffered 


670  THE  ROENTGEN  RAYS  IN  MEDICINE  AND  SURGERY 

from  eczema  for  years,  one  all  his  life.  In  one  case  the  disease  was  so  serious 
that  life  had  been  burdensome  for  months,  and  the  odor  emitted  made  the  patient 
offensive  to  those  about  him.     In  all  these  cases  the  X-rays  gave  wonderful  relief. 

X-Ray  Exposures.  —  Exposures  of  5  minutes'  duration  may  be  made  every 
other  day,  in  some  cases  every  day,  with  the  anode  of  the  tube  at  a  distance  of 
15  or  20  centimetres. 

Greater  care  should  be  exercised  to  prevent  over-exposure  in  this  than  in  other 
diseases  of  the  skin  ;  and  in  treating  eczema  of  the  face,  the  eyebrows  and  eye- 
lashes should,  of  course,  be  carefully  protected. 

In  one  of  my  patients  the  eczema  was  in  the  scalp  and  in  the  parts  of  the  face 
covered  by  the  beard ;  but  by  using  great  care  the  disease  was  efficiently  treated 
without  causing  the  hair  to  fall  out. 

Most  local  treatment  should  be  given  up  when  the  X-rays  are  used ;  the  use 
of  any  ointments,  oxide  of  zinc,  particularly,  which  would  interfere  with  the 
passage  of  the  rays,  should  be  especially  interdicted. 

Recurrence.  —  The  eczema  may  reappear  but  seems  more  apt  to  occur  in 
parts  that  have  not  been  previously  treated  by  the  X-rays. 

Acne  Vulgaris  and  Acne  Rosacea 

]\Iy  own  experience  with  these  diseases  has  been  limited  to  a  few  cases,  but  the 
results  have  been  very  satisfactory.  It  is  gratifying  to  be  able  to  convert  the 
complexion  of  a  young  woman  that  is  repulsive  into  one  that  is  more  than  tolerably 
good. 

X-Ray  Exposures.  —  The  exposures  in  acne  should  ordinarily  be  of  10 
minutes'  duration,  a  little  longer  than  in  the  cases  of  eczema,  with  the  tube  at  a 
distance  of  20  centimetres.  They  should  not  be  given  oftener  than  three  times  a 
week,  and  the  frequency  should  be  reduced  if  too  much  irritation  is  caused. 

When  the  acne  pustules  and  comedones,  if  these  also  are  present,  are  near 
together  and  there  are  many  of  them,  the  area  exposed  at  once  should  be  large 
enough  to  include  a  number  ;  but  when  they  are  isolated  the  opening  in  the  metal 
shield  should  be  only  a  Httle  larger  than  the  given  pustule  in  order  not  to  expose 
unnecessarily  any  portion  of  the  face,  if  that  is  the  part  attacked.  The  come- 
dones are  pushed  above  the  surface  after  several  exposures,  and  finally  fall  off  or 
are  brushed  off. 

To  carry  out  this  treatment  requires  time,  patience,  and  great  care,  for  no  risk 
should  be  run  of  producing  an  X-ray  burn  on  the  face ;  but,  on  the  contrary, 
every  precaution  should  be  exercised  to  expose  the  parts  it  is  desired  to  treat  and 
those  only ;  Hkewise,  as  is  pointed  out  below,  due  regard  should  be  had  to  the 
effects  on  the  skin  in  later  years. 

Dr.  Gautier^  (Paris)  reports  that  in  fifteen  cases  of  acne  vulgaris  and  acne 
rosaceae  the  advantages  of  X-ray  treatment  have  been  very  great.  He  recom- 
mends a  daily  sitting  of  5  or  6  minutes'  duration  with  the  tube  at  a  distance 

1  "Traitement  de  I'acne  et  de  la  couperose  par  les  rayons-x,"  Compies-renJiis  dii  XII  Coiigres 
International  de  Medecine,  Moscou,  August,  1897,  PP-  385-386. 


APPENDIX  5^  J 

of  30  centimetres,  and  a  current  of  6  amperes  and  18  to  20  volts.  The  good 
effect  in  these  cases  became  apparent  after  the  sixth  sitting ;  the  skin  peeled,  the 
acne  grew  paler,  the  vessels  were  less  apparent.  Later,  white  ribbon-like  masses 
were  seen  to  appear  between  the  nodules  and  the  patches  of  acne  rosacea. 

Dr.  Pakhitonov '  (Paris)  reports  a  case  of  a  woman  twenty-three  years  of  age 
who  had  suffered  from  acne  vulgaris  since  she  was  thirteen  years  old.  She 
improved  under  treatment,  but  was  not  completely  cured.  Dr.  Pakhitonov  sent 
her  to  Dr.  Gautier  for  baths,  which  soothed  the  general  irritation,  but  the  patches 
persisted.  They  finally  decided  to  use  the  X-ray  treatment,  and  after  twelve 
exposures  the  patches  were  completely  blanched. 

Hahn-  reports  two  cases  of  acne  rosacea  in  which  he  obtained  excellent 
results.  The  redness  of  the  nose  and  of  the  contiguous  parts  disappeared,  and 
months  had  elapsed,  when  this  report  was  made,  without  a  recurrence. 

Dr.  R.  R.  Campbell^  reports  fifteen  cases  of  acne  that  he  treated  with  the 
X-rays ;  the  exposures  as  a  rule  were  of  10  minutes'  duration,  with  the  tube  at  a 
distance  of  10  to  15  centimetres.  The  cases  were  not  selected.  The  first  one 
came  under  treatment  early  in  January  and  the  last  on  March  19,  1902.  In  nine 
of  these  fifteen  cases  the  results  were  excellent  and  there  had  been  no  recurrence 
when  they  were  reported ;  one  of  the  nine  was  a  brunette  and  a  slight,  passive 
pigmentation  was  produced,  but  no  erythema  or  dermatitis  ;  in  four  of  the  fifteen 
cases  a  few  papules  were  left ;  in  one  case  the  eruption  disappeared  except  in  the 
neighborhood  of  the  hair,  and  this  part  was  not  treated  on  account  of  the  depila- 
tory effects  of  the  X-rays.  In  one  case,  after  the  patient  had  been  under  treat- 
ment for  three  months,  January,  February,  and  Marcii,  1902,  and  had  been  given 
thirty-three  exposures  of  10  minutes  each,  with  the  tube  at  a  distance  of  10 
to  15  centimetres,  a  slight  dermatitis  was  produced,  but  no  improvement  had 
taken  place  in  the  local  conditions.  Dr.  Campbell  thought  the  treatment  a 
failure  in  this  case  and  advised  discontinuance  of  it.  The  patient  therefore  went 
home  reluctantly,  but  on  June  24,  1902,  wrote  him  that  the  eruption  on  the  fore- 
head and  cheeks  had  disappeared,  but  that  the  lesions  on  the  chin  still  remained, 
though  they  had  somewhat  improved.  Dr.  Campbell  calls  attention  to  this  case 
as  it  illustrates  the  accumulative  effects  of  the  X-rays,  and  indicates  the  necessity 
of  careful  treatment  in  order  to  accomplish  good  results  and  avoid  disastrous 
effects.  One  of  the  cases  already  mentioned  was  of  especial  interest  in  that  the 
goitre  from  which  the  patient  was  also  suffering  had  almost  disappeared  after  the 
treatment  by  the  X-rays  that  was  given  for  the  acne. 

Hyde,  Montgomery,  and  Ormsby  *  report  two  extensive  and  severe  cases  of 
acne,  in  which  the  eruptive  symptoms  disappeared  under  the  use  of  the  X-rays ; 

1  "  L'acne  et  les  rayons-x,"  Comptes-rendus  da  XII  Coiigrh  Internaiioual  de  MeJecine, 
Moscou,  August,  1897,  pp.  382-385. 

2  Fortschritte  a.  d.  Geb.  der  Roaitgenstr.,  B.  IV,  H.  2,  pp.  95-96. 

3  "Results  obtained  in  the  Treatment  of  Acne  by  Exposure  to  the  X-Rays," /"'"■"'^^ -•^'"^'■'- 
can  Medical  Association,  August  9,  1902,  pp.  313-314- 

*  "  A  Contribution  to  the  Subject  of  Radiotherapy  and  Phototherapy  in  Carcinoma,  Tuber- 
culosis, and  Other  Diseases  of  the  Skin,"  /oumal  American  Medical  Association,  January  3, 
1903,  pp.  1-8. 


672      THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

in  some  cases  a  few  exposures  aided  the  other  treatment  employed.  These  writers 
think  that  in  cases  of  acne  confined  to  small  areas  the  X-rays  are  of  undoubted 
value  and  that  the  treatment  can  be  pushed  to  the  point  of  producing  atrophy  of 
the  affected  glands  and  follicles  ;  but  that  when  the  acne  is  more  widely  distributed 
and  new  areas  are  constantly  being  affected,  though  the  X-rays  give  temporary 
benefit,  they  cannot  be  expected  to  make  a  permanent  cure  unless  the  treatment 
is  carried  so  far  as  to  cause  general  atrophy  of  the  sebaceous  glands  of  the  face ; 
and  that  this  course  must  be  questionable  until  its  effect  on  the  skin  10  to  40 
years  later  is  known.  The  writers  further  believe  that  no  local  treatment  can  be 
ex[)ected  to  take  the  place  entirely  of  the  treatment  of  the  underlying  conditions 
on  which  many  cases  of  acne  depend. 

Prurigo,  Pemphigus  Foliaceus,  Lichen  Ruber  Planus 

Freund^  states  that  Scholtz  had  no  distinct  results  in  the  treatment  of  prurigo 
with  the  X-rays,  but  that  he  obtained  a  temporary  improvement  in  pemphigus 
foliaceus  and  observed  striking  results  in  lichen  ruber  planus,  retrogression  of  the 
papules  taking  place  with  scaling  and  pigmentation. 

2.    HYPERTROPHIES 
Elephantiasis,  Verruca,   Keratosis 

Elephantiasis.  —  Sorel  and  Soret  report  favorable  results  with  this  disease. 

JFiir/s.  —  Sjogren  and  Sederholm  -  have  found  the  X-rays  useful  in  the  treat- 
n)ent  of  warts.  I  have  also  found  that  warts  can  be  removed  by  the  X-rays,  but 
that  other  methods  of  treatment  are  simpler. 

Ke)-atosis  and  pre-epitheliomatous  growths  seem  to  yield  to  the  X-rays.  My 
experience  in  these  cases  has  been  satisfactory. 

3.    ATROPHIES 

Growth  of  Hair  stimulated  by  X-Rays 

The  X-rays  have  for  some  time  past  been  used  to  remove  superfluous  hair, 
but  it  seems  surprising  that  they  should  also  be  capable  of  stimulating  the  growth 
of  the  hair  in  patients  where  it  has  been  gradually  falling  out.  For  example,  one 
of  my  i)atients  who  had  a  skin  disease  over  a  considerable  area  of  the  body  and 
also  to  some  extent  in  the  scalp,  and  who  had  very  little  hair  on  the  top  of  his  head, 
desired  to  have  the  scalp  exposed,  although  I  cautioned  him  that  it  might  result 
in  a  loss  of  hair.  He  was,  however, -indifferent  to  this  effect.  The  hair  did  fall 
out  to  some  extent,  but  later  returned  with  renewed  vigor,  and  he  had  such  an 

1  Gruifiriss  der  Gesnmmteii  RnJiotherapie  filr  Praktische  Aerzte,  1903,  p.  240. 
-  "  Beitrag  zur  therapeutischen  Verwertung  der  Roentgenstiahlen,"  forlschritte  a.  d.  Geb. 
der  Koentgenstr.,  B.  I\^  H.  4,  pp.  145-170. 


APPENDIX  A--> 

"/  o 

increased  growth  of  hair  that  his  friends,  who  were  not  aware  of  what  had  been 
done,  commented  upon  it. 

Another  patient,  a  woman  who  was  losing  her  hair,  desired  to  try  the  effects 
of  the  X-rays.  Six  exposures  of  five  minutes  each,  with  the  tube  at  a  distance  of 
20  centimetres,  were  given  during  three  weeks,  and  at  the  end  of  this  time  the 
hair  on  the  top  of  the  head  began  to  come  out  freely.  Over  the  area  that  had 
been  treated  a  barely  perceptible  reddening  of  the  scalp  could  be  seen.  A  few 
weeks  later  this  area  was  covered  with  quite  a  thick  growth  of  short  hair,  which 
more  than  replaced  the  hair  which  had  been  lost. 

The  risks  of  this  treatment  are  obviously  great,  as  at  present  it  is  difficult  to 
adjust  the  dose  of  the  X-rays  in  such  a  way  as  to  accomplish  only  the  desired 
result,  that  is,  to  stimulate  the  growth  of  the  hair  without  causing  it  to  fall  out. 

Alopecia  Areata 

Freund  ^  reports  a  case  of  alopecia  areata  treated  by  R.  Kienbock  by  means 
of  the  X-rays.  The  patient  had  suffered  from  this  disease  three  years.  Kienbock 
gave  the  front  of  the  head  six  exposures  of  fifteen  minutes  each  with  the  tube  at  a 
distance  of  20  centimetres.  What  hair  there  was  in  this  region  fell  out,  and  two 
months  later  vigorous,  dark,  normal  hair  appeared.  On  the  untreated  portions 
of  the  head  the  alopecia  remained,  and  Kienbock  drew  the  conclusion  that  the 
X-rays  and  depilation  led  to  a  new  growth  of  normal  hair. 

Freund  also  cites  a  case,  treated  by  G.  Holzknecht,  in  which  similar  results  were 
produced.  In  this  case  five  exposures  of  ten  minutes  each  were  given  with  the 
tube  at  a  distance  of  20  centimetres.  The  hair  did  not  fall  out  so  completely  at  first 
as  in  Kienbock's  case,  but  some  thick,  black  hair  remained,  so  that  every  bald 
patch  was  surrounded  by  a  circle  of  black  hair.  The  new  growth  of  hair  appeared 
in  the  areas  that  had  been  bald  before  treatment  by  the  X-rays  was  begun,  and 
two  months  after  the  rings  of  hair  had  fallen  out  new  hair  began  to  appear  in 
these  regions.  Holzknecht  had  similar  results  in  two  other  cases.  But  Freund 
states  that  Holzknecht,  Kienbock,  and  he  himself  have  had  refractory  cases  of 
alopecia  areata,  and  goes  on  to  say  that  for  the  present  the  hope  that  the  X-rays 
will  be  a  cure  for  a  general  alopecia  that  has  been  looked  upon  as  incurable  must 
be  given  up. 

Freund  believes  that  an  absolute  depilation  is  not  necessarily  recpiired,  but  that 
the  X-rays  need  merely  be  used  to  stimulate  into  activity  the  papilLx  of  the  hair  : 
that  they  may  be  used  in  cases  of  alopecia  areata,  which  would  improve  spon- 
taneously or  under  the  use  of  other  therapeutic  methods,  but  that  the  X-rays  bring 
about  quicker  results  than  treatment  by  drugs  ;  that  the  X-rays  are  not  a  specific 
cure  in  these  cases,  and  their  power  to  make  the  hair  grow  is  not  so  sure  as  their 
power  to  make  it  fall  out,  but  that  nevertheless  the  fact  observed  by  Kienbock  is 
very  interesting  and  shows  how  the  same  means,  if  reasonably  used,  may  be  help- 
ful for  two  diametrically  opposite  purposes. 

1  Grundriss  der  Gesanunten  Radiotherapie  fur  Praktische  Aerzte,  1903,  pp.  221-224. 
2  X 


674     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

4.    SENSORY    DERMATO-NEUROSES 
Pruritus  Ani  and  Vulv.e 

Sjogren  and  Sederholm  ^  observed  that  the  itching  in  this  disease  was  favor- 
ably influenced  by  the  X-rays,  and  heahng  took  place  if  no  great  change  of  this 
part  of  the  skin  had  been  produced  by  the  original  disease,  and  if  the  cause  of  the 
itching  was  cured. 

Scholtz-  reports  a  severe  case  of  pruritus  vulvae  in  which  he  obtained  decided 
improvement. 

5.    PARASITIC   AFFECTIONS 

Cutaneous   Blastomycosis 

Hyde,  Montgomery,  and  Ormsby  ''  report  two  cases  of  cutaneous  blastomycosis 
in  which  the  borders  that  had  not  healed  under  treatment  by  iodide  of  potassium 
disappeared  after  twelve  and  sixteen  exposures  to  the  X-rays  respectively. 

6.    NEW  GROWTHS 

The  value  of  the  X-rays  as  an  aid  in  making  a  diagnosis  in  both  medical  and 
surgical  cases  is  already  recognized.  Their  beneficent  action  in  relieving  many 
forms  of  skin  diseases  is  well  established,  but  the  position  they  will  eventually  hold 
as  a  therapeutic  agent  in  the  treatment  of  cancer  is  still  to  be  determined.  The 
cases  thus  far  treated  are  too  few  in  number,  and  too  short  a  time  has  elapsed 
since  their  treatment  was  begun,  to  justify  as  yet  definite  conclusions.  The  sub- 
ject must  therefore  be  approached  without  undue  enthusiasm,  and  with  the  full 
realization  that  at  least  a  few  more  years  of  careful  study  are  needed  to  determine 
what  is  to  be  the  position  of  the  X-rays  among  the  legitimate  methods  of  treating 
new  growths  ;  but  the  considerable  number  of  articles  on  this  subject  given  at  the 
end  of  this  Appendix  shows  how  fully  interest  in  it  has  been  aroused,  and  a  study  of 
them  indicates  that  excellent  work  has  been  done,  notably  by  Sequeira,  Johnson 
and  Merrill,  Morton,  and  Pusey. 

Method  of  Treatment  in  Cases  of  Cancer 

Rules  regarding  the  length  of  exposure  and  the  distance  of  the  anode  from 
the  patient  cannot  be'  apphed  too  literally,  the  experience  of  the  practitioner 
must  be  the  guide  in  determining  exactly  what  should  be  done  in  the  individual 
case,  because  the  apparatus  used  by  one  physician  may  vary  very  much  in  power 
from  that  of  another.  The  following  general  directions  may  be  helpful  in  the 
treatment  of  new  growths. 

^  "  Beitrag  zur  therapeutischen  Verwertung  der  Roentgenstrahlen,"  Fortschriitc  a.  d.  Geb. 
der  Roeiitgetistr.,  B.  IV,  H.  4,  pp.  145-170. 

2  "Ueber  den  Einfluss  d.  Roentgenstrahlen  a.  d.  Ilaut  in  gesundem  u.  krankem  Zustande," 
Arch.  f.  Der  mat  u.  Syphilis,  Vol.  59,  1902,  p.  443. 

^  "A  Contribution  to  the  Subject  of  Radiotherapy  and  Phototherapy  in  Carcinoma,  Tuberculo- 
sis, and  Other  Diseases  of  the  Skin,"  Journal  American  Medical  Association,  January  3,  1903, 
pp.  1-8. 


APPENDIX 


Small  Growths 


6/5 


Distance  of  Tube.  —  The  tube  may  be  first  placed  at  a  distance  of  20  centi- 
metres, and  if  there  is  no  reaction  after  a  few  exposures,  this  distance  may  be 
shortened  to  15  centimetres. 

Length  and  Frequency  of  Exposures.  —  The  first  exposures  may  be  of  5  to 

10  minutes'  duration ;  but  if  after  a  few  exposures  given  during  the  course  of 

two  weeks  too  much  reaction  should  be  excited,  this  time  should  be  shortened. 

The    exposures   should   not   be   given   oftener  than  three  times  a  week.     An 

interval  between  the  sittings  is  desirable,  as  otherwise  the  accumulated  effects 

of  the  X-rays,  which   manifest  themselves   only  after  some   time,  might  be   in 

excess  of  what  is  desired.     When  the  development  of  rapidly  increasing  moist 

;  growths  is  arrested  and  improvement  becomes  obvious,  the  exposures  may  be 

given  less  often,  twice  instead  of  three  times  a  week.     By  this  procedure'  the 

physician  can  watch  more  carefully  the  process  of  healing  and  avoid  too  violent 

1  treatment.     It  has  seemed  to  me  that  when  the  progress  of  these  growths  was 

(  once  arrested  and  improvement  had  begun,  nature  needed  less  assistance  from 

1  the   X-rays   than    at  first.     This   observation  does  not   apply   to    dry,   indolent 

.  growths,    such    as    many    forms   of  rodent   ulcer  which   require   more   vigorous 

treatment  along  dry,  indurated  edges. 

In  treating  new  growths  some  ingenuity  must  be  used  in  certain  cases  to 
make  them  accessible  to  the  X-rays  without  injuring  the  neighboring  parts. 
The  following  cases  are  illustrative  :  — 
I  Netv  Groivths  on  the  Eyelid.  —  When  it  is  necessary  to  expose  strongly  new 
;  growths  on  the  eyelid,  the  small  instrument  used  by  ophthalmologists  for  raising  the 
'  lid  may  be  modified  to  suit  this  need.  One  form  of  this  instrument  is  made  of 
'  bent  silver  wire,  and  that  portion  of  it  which  goes  under  the  lid  can  be  made 
[  solid  by  soldering  a  piece  of  metal  across  it,  and  inserted  under  the  part  of  the  lid 
I  occupied  by  the  new  growth  to  protect  the  eyeball  from  the  X-rays.  The  usual 
'1  outer  shield  to  protect  the  parts  surrounding  the  new  growth  is  then  placed  in 
!  position,  and  by  means  of  these  appliances  and  the  tube  holder  painted  with 
;  several  coats  of  white  lead,  the  new  growth  only  is  exposed  to  the  X-rays. 

Netv  Growths  in  the  Ear.  —  The  following  case  illustrates  a  useful  method  of 
;  treating  growths  in  this  region  :  This  patient,  who  was  sent  to  me  by  Dr.  Wilson 
I  of  Bridgeport,  Conn.,  for  treatment  by  the  X-rays,  had  an  epithelioma  of  the  pos- 
'  terior  wall  of  the  auditory  canal  that  had  been  operated  on  and  had  recurred. 
I  placed  the  patient  on  the  stretcher  already  described  and  figured,  and  in- 
serted into  the  canal  a  speculum,  one  lip  of  which  was  made  of  aluminum  and  the 
,  other  of  silver  ;  by  means  of  this  silver  the  healthy  part  of  the  canal  was  protected 
1  from  the  rays  while  the  other  was  exposed.  The  external  ear  and  hair  were  shielded 
j  from  the  rays  by  sheet  lead  placed  around  the  speculum  and  by  the  box,  painted 
i  with  white  lead  and  enclosing  the  tube,  already  described.  This  growth  healed. 
I  Neio  Gro7vths  in  the  Mouth.  —  I  have  found  the  glass  speculum,  painted  on  the 
i  inside  with  white  lead,  and  employed  as  shown  in  Fig.  400,  useful  when  treat- 
j  ing  a  new  growth  in  the  mouth.     It  will  also  be  of  assistance  in  other  cavities. 


676     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

Dr.  E.  \V.  Caldwell  ^  of  New  York  has  described  a  new  tube  for  thera- 
peutic applications  of  the  Roentgen  rays  to  the  larynx,  tongue,  prostate,  cervix 
of  uterus,  vagina,  etc. 

The  target  in  these  tubes  is  placed  at  the  end  of  a  tubular  projection  on  the 
spherical  portion  of  the  tube.     Over  this  projection  is  a  tubular  hood  of  sheet 


Fir,.  400.  Glass  speculum,  painted  inside  with  white  lead,  to  be  used  for  treating  new  growths  in 
cavities.  The  flaring  edge  of  the  speculum  shields  the  parts  under  it,  and  the  sheet  of  pure  tin  is  a 
further  protection.  The  section  of  the  tube  holder  and  the  tube  are  shown  above  the  speculum.  A 
glass  diaphragm  only  may  be  used  in  the  lower  part  of  the  tube  holder,  as  shown  in  the  cut,  or  an  addi- 
tional one  of  sheet  lead  may  be  placed  above  it.  The  aluminum  screen,  0.25  millimetre  thick,  shown 
in  the  cut,  is  grounded  by  a  wire. 

metal,  which  has  an  aperture  through  which  the  X-rays  pass,  and  therefore 
the  hood  limits  the  area  exposed  to  their  action.  (Instead  of  a  hood  this 
portion  of  the  tube  can  be  painted  with  white  lead,  as  has  been  done  by 
E.  E.  Fewkes  in  other  kinds  of  tubes.)  As  the  anode  is  brought  very  near  the 
part  to  be  treated,  long  exposures  are  not  required.  It  is  stated  that  these 
tubes  may  be  best  used  on  a  small  static  machine. 

^  A'ezv  York  Medical  Journal,  July  12,  1902. 


APPExNDIX  5y7 

Cancer  of  the  Breast 

In  treating  larger  growths,  such  as  inoperable  cancer  of  the  breast,  it  may  be 
necessary  to  increase  the  length  of  the  exposures  and  make  them  as  long  as  the 
skni  will  bear,  and  even  sometimes  to  excite  a  slight  dermatitis.  The  cases  which 
permit  the  greatest  length  of  exposure  are  those  in  which  there  is  a  large  ulcerat- 
ing surface  or  a  considerable  mass  of  diseased  tissue.  The  exposures  in  these 
cases  should  be  made  two  or  three  times  a  week,  and  should  be  of  longer  duration 
than  under  any  other  circumstances.  The  effect  of  this  energetic  treatment  is  to 
soften  the  induration  and  cause  profuse  discharge.  After  the  mass  has  been  thus 
disposed  of,  improvement  usually  takes  place  quite  rapidly.  Great  care  should  be 
taken  to  intermit  the  treatment  should  any  symptoms  of  toxaemia  arise  due  to 
absorption  from  the  growth. 

When  the  skin  is  unbroken  the  treatment  cannot  be  pushed  as  when  there  is 
an  open  ulcerating  surface.  The  X-rays  applied  to  a  large  mass  underneath  an 
unbroken  skin,  particularly  when  the  new  growth  is  of  a  nature  that  increases 
rapidly,  softens  that  mass  in  some  cases,  and  portions  of  it  are  slowly  absorbed. 
This  process  may  give  rise  to  symptoms  affecting  the  general  condition  of  the 
patient,  therefore  it  is  necessary  to  proceed  cautiously  in  those  cases  in  which 
the  products  of  the  changes  set  up  by  the  X-rays  cannot  find  a  ready  outlet  to  the 
surface.  The  elimination  of  these  products  from  the  system  is  desirable  ;  whether 
it  is  wise  in  cases  of  cancer  of  the  breast,  where  the  skin  is  unbroken,  to  apply 
the  X-rays  over  a  very  small  area  so  vigorously  as  to  cause  a  deep  ulceration 
and  thus  allow  drainage,  is  a  question  for  experience  to  determine. 

In  treating  cancer  of  the  breast,  whether  primary  or  after  operation,  with  the 
X-rays,  not  only  should  the  site  of  the  disease  be  exposed,  but  also  the  glands, 
which  might  become  affected,  and  the  whole  shoulder  and  neck ;  likewise  the 
other  breast,  for  it  should  be  remembered  that  the  growth  is  liable  to  appear  in 
the  latter  breast. 

Patients  should  report  at  intervals  of  a  month,  for  a  time  after  cessation  of 
treatment,  whether  they  have  been  suffering  from  a  smaller  or  a  larger  growth. 

The  method  of  treating  new  growths  which  I  have  used  is  less  severe,  as  a  rule, 
than  is  usually  recommended.  The  disadvantage  of  this  milder  treatment  is  that 
more  exposures  are  required  ;  but  on  the  other  hand,  there  is  less  likelihood  of 
exciting  so  much  reaction  as  to  cause  the  new  growth  to  spread  or,  in  larger 
forms,  of  causing  toxaemia. 

The  following  tables  give  in  some  detail  and  a  summary  of,  respectively,  150 
cases  of  new  growths  that  have  come  under  my  care  prior  to  January  i,  1903. 
I  do  not  include  those  subsequent  to  this  date,  as  their  treatment  is  too  recent  to 
make  them  of  much  value,  nor  the  post-operative  cases. 

These  150  cases  may  be  subdivided  into  smaller  new  growths,  loi  ;  larger 
new  growths,  such  as  those  of  the  jaw,  neck,  and  leg,  18  ;  cancer  of  the  breast,  31. 

In  carrying  out  the  treatment  in  a  large  proportion  of  these  patients  at  the 
Boston  City  Hospital,  I  have  had  the  efficient  assistance  of  Dr.  S.  W.  Ellsworth. 


678      THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 


J2 

a 

S 

V 

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coming 
Improved 

Has  been  well  since  Sep- 
tember, 1901 
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JU3UUB3JX  -"spun. 

<i>        >Jf        >ii            *       *     *               * 

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Lip 

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Ulceration  and  Necrosis 

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M     «     r^.*iovO     t^oo     O^O     «     «     r*'.    -^    trt  ^     r^oo     OvO     -     N     f^..j-mvc     f^<^ 

APPENDIX 


679 


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68o     THE    ROEXTGEX    RAYS    IN    MEDICINE    AND    SURGERY 


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After  first  operation,  Lymph  1- 
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682      THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 


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APPENDIX 


683 


SMALLER    NEW   GROWTHS 

The  following  table  is  a  summary  of  the  results  in  the  loi  cases  of  smaller  new 
growths  :  — 

One  Hundred  and  One  Smaller  New  Growths  treated  bv  X-Rays 


Healed  — 

Carcinoma  .         .         .         .         . 

Epidermoid  carcinoma  (Epithelioma) 
Rodent  ulcer        .         .         .         .         . 
Spindle-celled  sarcoma 
Ulceration  and  necrosis 


Under  Treatment  — 

Carcinoma  ..... 

Epidermoid  carcinoma  (Epithelioma) 
Rodent  ulcer        .... 


Discontinued  Treatment  — 

Epithelioma  .... 
Keratosis  .  .  .  .  • 
Rodent  ulcer        .... 

Not  Healed  — 

Carcinoma  ..... 
Epidermoid  carcinoma  (Epithelioma) 
Rodent  ulcer        .... 


5 
44 
8 
I 
I 


14 


59 


17 


7 

lOI 


The  fifty-nine  healed  cases  have  been  well  from  periods  varying  from  more 
than  two  years  to  over  two  months.  Only  a  very  few  have  been  healed  for  the 
longer  period  mentioned. 

The  following  cases  show  how  healing  may  follow  the  use  of  the  X-rays  with 
a  minimum  amount  of  disfigurement. 


684     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

Case  14.  Alfred  T.,  thirty  years  of  age.  Patient  of  Dr.  F.  E.  Cheney.  Mi- 
croscopical diagnosis,  epidermoid  cancer  of  the  lower  lid.  History  :  the  growth 
began  as  a  small  sore  under  the  lid  in  September,  1900  ;  in  ^Slay,  1901,  the  growth 
was  about  half  as  large  as  a  pea;  in  July,  1901,  the  lower  lid  was  gone  and  the 
growth  was  rapidly  extending  on  the  cheek.  When  the  patient  was  sent  to  me 
for  treatment  by  the  X-rays,  the  growth  was  5  by  2  by  i  h  centimetres  in  extent. 


*^. 


f 


Fig.  401.    Case  14,  Alfred  T.    Microscopical  diagnosis,  epidermoid  cancer  of  the  lower  lid.     Before 

treatment  by  the  X-rays. 

X-Ray  Exposures.  The  first  exposure  was  of  fifteen  minutes'  duration  ;  after 
an  interval  of  four  days  a  second  of  twenty  minutes  was  given,  and  on  the  two  fol- 
lowing days  two  exposures  of  twelve  minutes  each  were  giv'en.  Improvement  was 
noticeable  after  the  second  exposure.  During  the  following  four  weeks,  exposures 
of  about  five  minutes  each  were  made  daily,  except  on  Sundays,  and  during  the 
next  three  weeks  every  other  day  except  on  Sundays.  At  this  time  the  second 
photograph  (see  Fig.  402)  was  taken. 


Fio.  402.  Case  14,  Alfred  T.  After  treatment  by  the  X-rays,  but  a  short  time  before  healing  was 
fully  accomplished.  There  is  some  oedema  of  the  upper  lid  which  followed  an  incision  made  in  its 
outer  end  in  order  to  free  it  and  enable  me  to  reach  the  growth  there  more  easily.  The  ulceration  of 
the  cheek  healed  completely,  leaving  but  slight  scar.     He  has  been  well  a  year  and  a  half. 

Case  15.  Thomas  H.  G.,  sixty  years  of  age.  Microscopical  din^^nosis  by 
Dr.  Mallory  of  the  Boston  City  Hospital,  epidermoid  carcinoma.  Growth  of 
seven  to  eight  years'  duration.  In  July,  1901,  when  the  patient  was  referred  to 
me  by  Dr.  M.  F.  Gavin,  there  was  an  ulcerated  surface  on  the  right  temple,  as 
shown  in  Fig.  403. 

X-Ray  Exposures.  Five  exposures  of  ten  minutes  each  were  given  on  consec- 
utive days,  and  were  followed  by  exposures  of  three  minutes  each  for  two  days. 


APPENDIX 


685 


The  treatment  was  then  stopped  for  two  weeks  ;  at  the  end  of  this  time  healing  had 
taken  place  over  half  the  original  area.     The  exposures  were  then  resumed,  and 


WiB' ' 

8^^^'' 

W^-:, 

—   *  1* 

Fig.  403.      Case  15,  Thomas  H.  G.     Microscopical  diagnosis,  '■.pidcrmoid  carcinoma.     Before  treat- 
ment by  tlie  X-rays. 

were  given  once  a  week  for  five  weeks,  and  were  of  three  minutes'  duration.     At 
the  end  of  this  time  complete  healing  had  taken  place. 


Fig.  404.     Case  15,  Tliomas  II.  G.     Alter  treatment  1  y  tlie  X-rays. 


Case  53.      John  M.  D.,  seventy-five  years  of  age.      The  clinical  diagnosis 
in  this  case  was  epithelioma  of  the  nose,  which  was  of  six  years'  duration.    I  gave 


!     Fig.  405.      Case  53,  John  M.  D.     Clinical  diagnosis,  epithelioma.     Before  treatment.     Steady  im- 
'  provement  has  followed  the  use  of  the  X-rays. 


686     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

this  patient  six  exposures  of  five  or  ten  minutes  each,  and  he  improved  rapidly. 
The  photograph  ft-om  which  Fig.  405  was  made  was  taken  before  treatment  by 
the  X-rays. 


l-'ic.  406.     Case  53,  ]ohn  M.  D.     Alter  treatment  by  the  X-rays.     Last  exposure  July  30,  1902. 


Fig.  407.     Case  89,  L,  S.,  sixty-five  years  of  age.     Ciinicni  diagnosis,  epitlieiioma  of  lower  lid.    Dura- 
tion one  year.    Before  treatment  by  the  X-rays. 


Fig.  408.    Case  89,  L.  S.     After  treatment  by  the  X-rays. 


APPENDIX 


687 


Fig.  409.  Case  92,  S.  T.,  seventy-five 
years  of  age.  Clinical  diagnosis,  epitheli- 
oma of  nose.  Duration  two  years.  Before 
treatment  by  the  X-rays. 


Ik;.  410.    Case  92,  S.  T. 
by  ihe  X-rays. 


After  treatment 


Fig.  411.  Case  67,  E.  M.,  fifty  years 
of  age.  Clinical  diagnosis,  epithelioma 
of  lid.  Duration  thirteen  years.  Be- 
fore treatment  by  the  X-rays. 


V\r..    412.      <  a--    '-7.    l-^-    M- 
treatment  by  the  X-rays. 


688     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 


Fig.  413.    Case  148,  G.  P.,  fifty-one  years  of  age.     Microscopical  and  clinical  diagnosis,  rodent  ulcer 
of  nose.     Duration  eight  years.     Before  treatment  by  the  X-rays. 


Fig.  414.     Case  148,  G.  P.     After  twenty-two  exposures.     Healing  complete  three  days  later. 


APPENDIX  68g 

Case  59.  Mrs.  S.,  fifty-seven  years  of  age.  Clinical  diagnosis,  epithelioma 
of  cheek.  This  growth  began  six  years  ago  as  a  small  pimple  and  grew  much 
more  rapidly  during  the  fifth  year  than  at  first.  The  photograph  (Fig.  415)  was 
taken  after  two  exposures  of  ten  minutes  each  had  been  made,  and  when  the 
edges  of  the  cavity  had  begun  to  contract  as  a  result  of  the  exposures.  The 
patient  improved  rapidly,  and  after  six  more  exposures  of  five  minutes  each,  given 


Fig.  415.    Case  59,  Mrs.  S.     Clinical  diagnosis,  epithelioma  of  cheek.     Photograph  taken  after  two 
exposures  often  minutes  each  to  the  X-rays. 


twice  a  week,  the  growth  was  only  half  the  size  it  was  when  this  treatment  was 
begun.     The  exposures  were  continued,  and  the  results  are  shown  in  Fig.  416. 

Case  45.  Arthur  B.,  six  years  of  age,  patient  of  Dr.  C.  T.  Gardner  of  Provi- 
dence. Vaccinated  September,  1900  ;  small  lump  near  the  scar  was  noticed  March, 
1901,  removed  June,  1901  ;  returned  again  and  removed  September,  1901.  The 
microscopical  diagnosis  showed  it  was  made  up  of  small  spindle  cells,  irregularly 
arranged  and  closely  packed  together.  Returned  December,  1901  (see  Fig.  417). 
X-ray  treatment  January,  1902  (see  Fig.  418). 

In  this  case  we  have  an  opportunity  for  direct  comparison  between  the  readi- 
ness with  which  recurrence  has  taken  place  after  operation  and  the  freedom  from 
it  already  obtained,  after  the  use  of  the  X-rays,  that  is  for  one  year. 


690 


THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 


Of  the  eighteen  cases  under  ireatmeni  more  than  half  seem  Hkely  to  heal. 
One  of  these  cases  was  a  man  who  had  carcinoma  of  the  nose.  He  was  first  treated 
in  September  and  October,  1901  ;  on  the  second  day  of  the  following  November, 
although  a  slight  induration  remained,  he  said  he  was  obliged  to  go  away.  Six- 
teen months  later  he  returned  to  be  examined,  and  I  found  the  induration,  which 


Fig.  416.     Case  59,  Mrs.  S.     After  treatment  by  the  X-rays. 

had  never  entirely  disappeared,  a  little  larger  in  extent.  I  advised  him  to  resume 
treatment,  which  he  did. 

The  seventeen  cases  that  discontinued  treatment  did  so  for  such  reasons  as 
the  following  :  the  patients  thought  they  were  well,  or  they  lived  too  far  away  to 
be  able  to  come  and  wished  for  treatment  nearer  home  ;  one  died  of  renal  disease. 
Most  of  these  cases  were  doing  well  when  I  lost  sight  of  them. 

The  seven  not  healed  cases  are  as  follows  :  one  was  a  carcinoma  of  the 
nose  upon  which  several  operations  had  been  done  prior  to  the  use  of  the  X-rays; 


APPENDIX  6gi 

this  treatment  for  a  time  promised  well,  but  improvement  did  not  continue  and 
another  operation  was  performed ;  three  were  cases  of  epithelioma  of  the  lip, 
one  of  the  lip  and  chin,  and  one  of  the  cheek,  involving  the  zygomatic  arch.  I 
advised  an  operation  in  the  latter  case,  as  improvement  under  treatment  by  the 
X-rays  was  not  satisfactory.  Three  of  these  five  patients  I  know  to  be  living ;  of 
the  remaining  two,  one  of  the  lip  cases  and  the  lip  and  chin  case,  I  have  had  no 


Fig.  417.    Case  45,  Arthur  B.     Microscopical  diagnosis,  spindle-celled  sarcoma.    Before  treatment 

by  the  X-rays. 

news  of  late.  The  seventh  case  was  a  rodent  ulcer  of  the  forehead  in  which  a 
very  small  area  did  not  heal  under  treatment  by  the  X-rays.  This  area  was  treated 
by  the  actual  cautery. 

Rodent  Ulcers.  —  The  dry,  hard,  indolent  new  growths  with  raised,  worm- 
like edges,  usually  classed  under  the  head  of  rodent  ulcer  or  epidermoid  car- 
cinoma, I  have  found  to  heal  less  readily  by  the  X-rays  than  the  moist  ulcerating 
forms,  and  that  sometimes  a  small  remaining  corner  was  left  that  was  very  difficult 
to  heal.    In  some  of  these  cases  the  actual  cautery  has  been  used  rather  than  con- 


692      THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

tinue  the  use  of  the  X-rays  indefinitely.  I  do  not  feel  as  sure  of  the  permanency 
of  the  result  in  cases  of  rodent  ulcer  as  in  those  of  epithelioma.  Some  cases  of 
the  former  kind  persist  so  long,  even  under  the  constant  and  systematic  use 
of  the  X-rays,  that  though  this  treatment  may  be  a  valuable  addition  to  our 
therapeutic  resources  for  them,  its  best  opportunity  is  not  in  these  cases. 

Sequeira/  who  has  had  much  more  experience  than  I  have  had  in  this  class 
of  cases,  reported  in  September,  1901,  forty-five  cases  of  rodent  ulcer  that  he  had 


Fig.  418.  Case  45,  Arthur  B.  After  treatment  by  the  X-rays,  this  patient  has  been  well  for  a 
year,  a  longer  time  than  after  either  operation.  Operated  on  June  and  September,  1901.  Recurred 
again  December,  1901.     X-ray  treatment  begun  January,  1902. 

treated  with  the  X-rays  since  the  previous  June.  He  states  that  the  ulcers 
healed  rapidly  and  large  cavities  filled  up,  but  that  he  had  had  difficulty  with  the 
hard,  raised  edges.  He  had  also  observed  slight  recurrences,  which,  however, 
had  been  easily  controlled. 

Sequeira-  in  October,   1902,  reports  eighty  cases  of  rodent  ulcer,  thirty-four 

^British  Medical  Journal,  September  28,  1901,  p.  851. 
^British  Medical  Journal,  October  25,  1902,  pp.  1316-1317. 


APPENDIX  6q, 

of  which  were  healed,  and  the  majority  of  the  rest  were  under  treatment.  He 
found  infiltration  of  the  cartilage,  especially  of  the  nose,  and  the  involvement  of 
the  bone  and  the  pericranium  were  unfavorable  conditions.  He  again  states  that 
small  recurrences  occurred  in  some  cases,  but  in  others  sound  healing  had  taken 
place  and  there  had  been  no  recurrences  in  two  years.  He  also  again  lays  stress 
on  the  difficulty  of  causing  the  hard  edge  of  the  growth  to  disappear,  and  sug- 


Fig.  419.  Case  74,  Mrs.  L.,  sixty-nine  years  of  age.  Clinical  diagnosis,  epithelioma  of  orbit. 
Duration  ten  years.  Enucleation  three  years  ago  ;  second  operation  two  years  ago.  Before  treatment 
bv  the  X-ravs. 


gests  that   the   actual  cautery  would  probably  give  more  satisfactory  results  in 
these  parts. 

He  further  states  that  a  microscopical  examination  of  tissues  after  treatment 
by  the  X-rays  showed  that  the  epithelial  cells  were  destroyed,  and  in  some  cells  a 
fatty  change  had  taken  place  ;  that  the  connective  tissue  elements  were  also  stimu- 
lated, and  this  stimulation  led  to  the  filling  up  of  cavities  and  the  formation 
of  healthy  scar  tissue. 


694 


THE  ROENTGEN  RAYS  IN  MEDICINE  AND  SURGERY 


G.  H.  Lancashire^  roughly  divides  rodent  ulcers  into  two  classes,  the  ulcerated 
and  the  non-ulcerated  variety,  and  he  believes  that  the  former  respond  more 
readily  to  treatment  than  the  latter.  In  the  ulcerated  variety,  according  to  his 
observation,  the  hard  border  softens  after  being  treated  by  the  X-rays  for  two  or 
three  weeks,  and  later,  granulations  are  seen  springing  up  from  the  surface  of  the 
ulcer,  which  multiply  rapidly  and  in  time  raise  the  base  to  a  level  with  the  sur- 


■W^ 


*■  m^ 


Fig.  420.     Case  74,  Mrs.  L.     After  treatment  by  the  X-rays.     1  wenty-four  e.xposures  given. 


rounding  skin.  While  the  granulations  are  forming  the  border  softens  still  more 
and  grows  thinner  ;  later  the  ulcer  seems  to  be  a  simple  healthy  ulcer,  from  which 
the  malignancy  has  disappeared,  and  which  heals  in  the  ordinary  way,  leaving  a 
remarkably  smooth  and  supple  scar.  Lancashire  has  seen  two  cases  in  which 
during  the  healing  process  the  reaction  from  the  X-ray  exposures  was  too  strong, 
and  the  newly  formed  tissue  broke  down  with  rapidity.     The  treatment  was  sus- 

1  "The  Therapeutic  Employment  of   X-Rays,"    British  Medical  Joiinial,  May  31,   1902, 
P-  1330- 


APPENDIX 


695 


pended,  and  in  one  case,  when  last  seen  healing  was  going  on  again,  and  to  the 
naked  eye  there  was  no  appearance  of  a  rodent  ulcer. 

The  second  case  was  one  in  which  there  had  been  for  some  time  a  thick  crust 
on  the  deepest  part  of  the  ulcer  which  Lancashire  did  not  disturb.  The  tissues 
first  broke  down  under  this  crust,  and  on  removing  it  he  found  a  considerable 
amount  of  pent-up  material,  which  he  stated  must  have  been  rich  in  putrefying 
organisms  that  would  be  injurious  to  the  granulation  tissue.  When  the  relapse 
occurred  this  ulcer  was  two-thirds  healed,  and  Lancashire  hoped  it  would  recover 
the  ground  it  had  lost. 

Lancashire  states  that  the  non-ulcerated  class  of  ulcers  are  not  insignificant  in 
number,  and  that  they  not  infret^uently  remain  unrecognized  until  they  have  made 
considerable  progress ;  that  they  are  characterized  by  pale,  worm-like  ridges, 
hard  to  the  touch,  which  mark  the  advance  of  the  disease.  Cases  of  this  kind, 
that  Lancashire  has  seen,  have  reacted  after  a  time,  the  ridges  first  softening  and 
sometimes  being  slowly  absorbed  without  ulceration.  Generally,  however,  they 
broke  down,  the  ulceration  marking  well  the  sinuous  lines  which  formed  the  site 
of  the  thickened  epithelioma.  Elsewhere  the  scar  tissue  grew  softer  and  redder, 
and  eventually  the  patches  and  streaks  of  ulceration  healed  in  the  usual  manner. 
Lancashire  has  seen  only  one  case,  a  very  long-standing  and  extensive  ulcer,  that 
showed  apparently  no  response  to  X-ray  treatment. 

He  states  that  two  of  his  cases  of  rodent  ulcer  were  discharged  from  treat- 
ment 4  and  6  months  ago  respectively,  and  were  still  free,  when  reported  on,  from 
visible  recurrence.  He  suggests  that  it  is  wise  in  all  cases  to  continue  the  expos- 
ures for  a  while  after  cure  has  apparently  been  effected. 

Johnson  and  MerrilP  report  13  cases  of  epithelioma  treated  by  the  X-rays, 
10  of  which  were  apparently  cured,  2  were  improved,  i  of  these  is  still  under 
treatment,  and  i  was  not  benefited,  except  that  the  pain  was  alleviated  and 
the  discharge  diminished.  In  one  of  these  13  cases  the  last  exposure  was  given 
2I  years  ago,  in  a  second  2  years,  in  a  third  \\  years,  in  a  fourth  i  year,  in  one  8 
months,  in  three  6  months,  and  in  one  i  month  ago,  and  there  has  been  no 
recurrence  so  far  as  known. 

They  also  report  three  cases  of  rodent  ulcer ;  two  of  which  had  improved  and 
were  under  treatment  when  reported  on,  and  in  the  third  case  the  patient  had 
stopped  the  treatment;  likewise  two  cases  oi  fibroma  which  showed  no  change  ; 
these  latter  cases  Johnson  and  Merrill  state  they  would  not  have  treated  if  the 
patients  could  have  been  induced  to  submit  to  an  operation.  They  further  cite  one 
case  of  sarcoma  that  was  apparently  cured,  the  last  exposure  having  been  gi\'en  a 
year  ago,  when  the  case  was  reported,  but  the  patient  had  since  been  lost  sight  of. 

The  writers  give  a  table  with  further  data  concerning  these  19  cases.  The 
table  also  includes  7  inoperable  cases  of  carcinoma  in  which  pain  was  relieved, 
but  the  termination  was  fatal. 

Dr.  William  Allen  Pusey-  reports  a  case  of  sarcoma,  in  which  the  X-rays  were 
applied  with  success.     The  patient  was  a  man  twenty-four  years  of  age,  who  in 

1  "The  X-Ray  Treatment  of  Carcinoma,"  American  Medicine,  August  9,  1902,  pp.  217-218. 

2  "Cases  of  Sarcoma  and  of  Hodgkin's  Disease  treated  by  Exposures  to  X-Rays:  A  Pre- 
liminary XKiit^oxi;'  Jotirnal  of  the  American  Medical  Association,  January  18,  1902. 


696     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

February,  1901,  noticed  a  small  hard  swelling,  the  size  of  a  filbert,  below  the  angle 
of  the  jaw,  on  the  left  side  of  the  neck,  which  gradually  increased  in  size.    In  May, 

1901,  he  observed  a  similar  hard  swelling,  of  the  size  of  a  filbert,  on  the  right  side 
of  the  neck,  about  an  inch  below  the  mastoid  process,  which  increased  rapidly  in 
size.  Ten  weeks  later  the  condition  was  as  follows  :  a  hard  movable  swelling  the 
size  of  a  hen's  egg  just  below  the  angle  of  the  jaw  on  the  left  side,»which  was  not 
tender  or  painful ;  another  hard  mass  under  the  upper  third  of  the  sternocleido- 
mastoid muscle  on  the  left  side,  and  still  another  very  hard  mass,  the  size  of  a 
man's  fist,  on  the  right  side  of  the  neck,  below  the  ear  and  mastoid  process  ; 
neither  of  these  two  latter  masses  was  freely  movable,  tender,  or  painful.  The 
clinical  diagnosis  of  sarcoma  was  made  by  Dr.  Ochsner,  and  the  diagnosis  of 
small,  round-celled  sarcoma  by  Dr.  Zeit  after  a  microscopical  examination.  Dr. 
Ochsner  removed  the  tumors  on  the  left  side  ;  the  patient  made  a  speedy  recovery 
and  was  sent  to  Dr.  Pusey  on  September  2  for  a  month's  treatment  by  the  X-rays 
as  a  preliminary  to  a  second  operation.  Twenty-one  exposures,  varying  in  length 
from  10  to  15  minutes  each,  were  given  to  the  right  side  of  the  neck  between 
September  2  and  2  7  with  a  tube  of  high  resistance  which  gave  a  weak  light ;  the 
tube  was  placed  at  a  distance  of  5  centimetres  from  the  surface  treated.  On 
September  17  slight  erythema  appeared  ;  by  September  27  there  was  pronounced 
dermatitis,  which  increased  for  the  following  six  days,  and  then  rapidly  disappeared, 
and  by  October  12  was  almost  well.  The  tumor  decreased  in  size  during  the 
first  ten  days  of  treatment  by  the  X-rays,  and  on  October  1 1  there  was  no  trace 
of  the  disease  left  except  a  small  painless  gland  not  larger  than  the  kernel  of  an 
almond.  On  December  7  the  patient  reported  that  his  neck  seemed  to  be  in  as 
good  a  condition  as  it  ever  was,  and  that  the  gland  appeared  to  be  about  half 
as  large  as  the  kernel  of  an  almond.     This  report  was  repeated  on  January  12, 

1902,  and  the  patient  added  that  since  September  he  had  gained  twelve  pounds. 
Dr.  Pusey  states  there  is  no  doubt  that  the  tumor  on  the  right  side,  which  was 
treated  by  the  X-rays  alone,  was  of  the  same  character  as  that  on  the  left  side. 

April  12,  1902,  Dr.  Pusey^  makes  a  further  report  on  this  case.  On  March  10, 
1902,  the  patient  wrote  that  the  swelling  was  returning.  Dr.  Pusey  wished  to 
give  him  further  X-ray  exposures,  but  the  patient  was  unable  to  remain  in  the  city. 

Dr.  James  Francis  McCaw^  reports  a  case  of  primary  epithelioma  of  the 
uvula  and  velum  palati,  the  diagnosis  of  which  was  made  by  means  of  the  micro- 
scope. The  growth  was  first  excised  as  far  as  possible,  then  curetted  and  cauter- 
ized, and  two  weeks  later  exposed  to  the  X-rays.  The  exposures  were  made 
three  times  a  week  for  seven  weeks ;  at  the  end  of  the  first  week  the  patient 
stated  that  the  soreness  had  almost  entirely  left  her  throat,  and  at  the  end  of  two 
weeks  the  diseased  areas  were  in  a  state  of  healthy  cicatrization.  Three  weeks 
later  the  throat  seemed  entirely  healed,  but  examination  with  the  mirror  showed 
that  the  upper  posterior  surface  of  the  soft  palate  was  still  affected.     At  the  end 

1  "  Report  of  Cases  treated  with  Roentgen  Rays,"  Journal  of  the  American  Medical 
Association,  April  12,  1902,  pp.  911-919. 

2  "  Primary  Epithelioma  of  the  Uvula  and  Soft  Palate  and  Treatment  with  the  Roentgen 
Rays;   Report  of  a  Case,"  A^ew  York  Medical  Journal,  August  9,  1902,  pp.  225-227. 


APPENDIX  697 

of  the  seven  weeks  there  was  only  one  small  area  as  large  as  a  split  pea  remaining 
unhealed.  The  patient,  then  thinking  her  throat  well,  remained  away  for  three 
weeks.  At  the  end  of  this  time  the  diseased  area  had  increased,  and  the  growth 
was  again  thoroughly  curetted  and  cauterized.  A  portion  of  this  growth  was  ex- 
amined under  the  microscope,  and  the  result  confirmed  the  previous  examination  ; 
but  this  specimen,  unlike  the  first,  showed  that  there  had  been  a  rapid  colloid 
degeneration  of  the  epithelial  cells,  the  protoplasm  of  which  was  almost  entirely  re- 
placed by  colloid  material.  Treatment  by  the  X-rays  was  resumed,  the  exposures 
being  given  three  times  a  week  for  five  weeks  ;  at  the  end  of  which  time  there  was 
only  a  small  unhealed  area  on  the  velum  palati,  which  gave  every  indication  that 
it  would  soon  likewise  heal. 

Dr.  McCaw  examined  this  patient  later,  and  found  that  the  ulcerated  surfaces 
had  entirely  healed,  that  the  amount  of  scar  tissue  was  almost  unnoticeable,  and 
that  the  slight  degree  of  previous  contraction  of  the  velum  palati  had  disappeared, 
and  that  the  parts  worked  properly.  Dr.  McCaw  will  give  a  further  report  of 
this  case. 


LARGER    NEW   GROWTHS 

The   following   table   is   a  summary  of  the   results   in   eighteen   larger   new 
growths,  not  including  those  of  the  breast :  — 

Eighteen  Larger  New  Growths  treated  by  X-Ravs 


Healed 


Under  Treatment  — 

Carcinoma     ....... 

Lympho-sarcoma  and  round-celled  sarcoma 

Discontinued  Treatment  — 

Carcinoma     ....... 

Epidermoid  carcinoma  (Epithelioma)   . 

Not  Healed  — 

Carcinoma     ..... 
Epidermoid  carcinoma  (Epithelioma) 
Papilloma       ..... 
Spindle  and  round-celled  sarcoma 
Spindle-celled  sarcoma 


I3_ 
18 


698     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

The  first  case  still  under  treatment  is  that  of  a  girl,  twelve  years  of  age  (see 
Fi<^s.  421  and  422),  who  had  a  growth  of  seven  years'  duration.  Two  operations 
had  been  done  for  the  removal  of  large  masses  of  glands  in  the  neck,  one  by  Dr. 
G.  W.  Gay  and  the  other  by  Dr.  M.  W.  Richardson,  before  she  came  to  me  for 


Fig.  421.    Case  78,  A.  D.,  twelve  years  of  age.     Microscopical  diagnosis,  lympho-sarcoma  and  round- 
celled  sarcoma.     Duration,  seven  years.     Two  operations.     Before  treatment  by  the  X-rays. 

treatment  by  the  X-rays.  The  microscopical  examination  made  after  the  first 
operation  showed  that  the  growth  was  a  lympho-sarcoma,  and  that  after  the 
second  that  it  was  a  round-celled  sarcoma. 

The  growth  involved  the  glands  of  the  neck,  both  axillae,  groin,  and  thorax. 
The  accompanying  cut  shows  how  great  was  the  enlargement  of  the  glands  in  the 


APPENDIX 


699 


neck ;  those  in  the  other  portions  mentioned  were  also  very  greatly  enlarged. 
Treatment  was  begun  in  May,  1902,  and  during  the  first  three  weeks  the  glands 
became  softer  and  smaller,  and  the  patient's  well-being  was  much  improved.  She 
was  weak  and  listless  at  the  beginning  of  the  treatment,  but  became  bright  and 
active  after  the  lapse  of  three  or  four  weeks.     Exposures  have  been  given  once 


I 


Fig.  422.    Case  78,  A.  D.,  twelve  years  of  age.    After  treatment  by  the  X-rays. 
Still  under  treatment. 


700     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

or  twice  a  week,  as  a  rule,  during  ten  months.  During  the  seventh  month  of 
treatment  the  spleen  became  enormously  large,  extending  to  the  right  of  the 
umbilicus  and  nearly  down  to  the  iliac  crest,  but  after  X-ray  exposures  it  steadily 
diminished  in  size ;  the  weight  of  the  patient  has  constantly  increased. 

The  secontl  case  under  treatment  is  a  growth  in  the  thorax,  and  the  third  a 
growth  in  the  neck. 

The  first  case  tabulated  as  having  discontinued  treatment  was  that  of  an  epithe- 
lioma of  the  hand,  referred  to  on  page  432.  The  patient  was  a  hospital  case,  and 
ceased  to  come  for  treatment.  He  was  old  and  feeble,  and  I  think  would  not 
have  recovered.  The  second  patient  who  discontinued  treatment  had  a  cancer 
of  the  rectum,  and  was  not  relieved. 

The  thirteen  not  healed  cases  are  as  follows  :  two  were  growths  in  the  jaw 
that  had  recurred  after  operation,  which  were  relieved  by  treatment  with  the 
X-rays ;  three  were  new  growths  in  the  neck  that  were  much  relieved  by  the 
X-rays ;  one  of  these  was  a  recurrence  after  operation,  and  the  growth  largely 
healed  externally,  but  the  progress  of  the  disease  was  not  checked.  The  follow- 
ing cut  shows  the  condition  of  the  latter  case  before  treatment  by  the  X-rays  was 
begun. 

Case  58,  D.  R.  The  cut  of  this  patient  (see  Fig.  423)  shows  extensive  ulcer- 
ation over  the  angle  of  the  jaw,  under  the  ear,  and  extending  down  on  to  the  neck. 
Under  the  X-rays  the  external  portions  improved  very  much,  but  after  a  few 
weeks  it  was  evident  that  the  deeper  portions  of  the  growth  were  extending,  and 
the  patient  had  much  difficulty  in  swallowing.  Except  to  give  relief,  and  perhaps 
retard  the  progress  of  the  growth,  the  X-rays  did  not  avail. 

Four  of  the  thirteen  cases  were  growths  on  the  tongue ;  one  was  an  epi- 
thelioma of  the  tongue,  which  began  on  the  tip,  and  was  referred  to  in  the 
last  edition.  It  is  the  only  case  of  new  growth  on  the  tongue  I  have  seen  which 
offered  hope  of  being  healed  by  the  X-rays.  The  patient  came  early  for  treat- 
ment and  improved  very  much.  At  the  end  of  four  exposures,  one  of  fifteen,  one 
of  twelve,  and  two  of  seven  minutes  each,  he  could  talk  more  clearly,  the  indura- 
tion had  lessened,  and  the  growth  felt  smaller  to  the  patient.  He  then  discon- 
tinued treatment  with  the  X-rays,  by  the  advice  of  an  astrologer,  and  went  to  a 
friend  of  the  latter  for  treatment.     The  patient  has  since  died. 

The  eleventh  was  a  papilloma  of  the  larynx,  described  in  the  last  edition,  that 
improved  under  treatment,  the  suffocative  attacks  became  easier  and  the  hoarse- 
ness was  diminished,  but  later  the  patient  did  not  do  well. 

One  was  a  new  growth  in  the  leg  of  a  man,  sixty-seven  years  of  age,  who  had 
had  seven  operations,  the  first  five  years  ago.  X-ray  treatment  was  instituted  and 
carried  on  for  several  months,  the  exposures  being  given  usually  once  a  week, 
and  the  growth  diminished  in  size.  Then  the  treatment  was  discontinued  for 
several  weeks  ;  at  the  end  of  this  time  three  small,  raised,  soft,  dark  areas  of 
spindle-celled  sarcoma  appeared  in  the  wound.  Vigorous  treatment  was  given 
by  the  X-rays,  but  the  disease  did  not  yield,  and  amputation  was  advised. 

The  thirteenth  was  a  case  of  spindle-celled  sarcoma,  in  which  nearly  the 
whole   abdominal  wall   was  involved.     The    patient,   a   woman,   improved    very 


APPENDIX 


:'OI 


much  under  X-ray  exposures,  but  they  were  begun  in  so  late  a  stage  of  the 
disease  that  she  had  not  sufficient  strength  to  continue  to  come  for  treatment. 
Johnson  and  Merrill  ^  report  seven  cases  of  carcinoma,  all  of  which  were  classed 


Fig.  423.     Case  58,  Dennis  R.,  fifty  years  of  age.     Microscopical  diagnosis,  carcinoma.     Duration 
fifteen  months.     Before  treatment. 

as  inoperable  by  the  surgeon  who  referred  them.     None  of  these  showed  any 
improvement  except  relief  from  pain,  and  probably  a  delay  in  the  final  result. 

1"  The  X-Ray  Treatment  of  Carcinoma,"  American  Medicine,  .\ugust  9,  1902,  pp.  217-218. 


702      THE    ROENTGEN    RAVS    IN    MEDICINE   AND    SURGERY 


CANCER   OF    THE    BREAST 

A  summary  of  thirty-one  cases  of  cancer  of  the  breast  treated  by  the  X-rays 
is  given  in  the  following  table  :  — 

Thirtv-oxe  Cases  of  Canxer  of  the  Breast  treated  by  X-Rays 


Healed  — 

Carcinoma           ......... 

Sarcoma      ........... 

6 

I 

Under  Treatment  — 

7 

Carcinoma           .......... 

Paget's  Disease  .......... 

Scirrhous  Carcinoma  ......... 

II 

I 

I 

Discontinued  Treatment-^ 

13 

Carcinoma           .......... 

4 

Not  Healed  — 

Carcinoma           .          ......... 

Carcinomatous  glands  in  neck  after  breast  ..... 

Sarcoma 

4 

2 
I 

7 

31 

Six  of  the  seven  cases  that  healed  were  small  recurrences  in  the  site  of  the 
growth  after  operation  for  the  removal  of  the  breast,  except  in  one  case  where 
small  glands  were  involved.  The  seventh  case  was  a  primary  growth  in  the 
breast  of  a  man. 

In  eleven  of  the  thirteen  cases  still  under  treatment  the  growths  seem  to  be 
held  in  check  or  are  decreasing ;  two  are  not  improving. 

In  one  of  the  eleven  cases  the  patient  weighed,  before  treatment,  90  pounds. 
The  growth  was  cauliflower-like  in  character  and  projected  4  centimetres  above 
the  skin.  The  photograph  from  which  Fig.  424  was  made  was  taken  at  this  time. 
Figure  425  shows  the  improvement  that  has  taken  place  under  treatment  by  the 
X-rays.  The  patient  weighed  when  this  cut  was  made  116^  pounds,  and  has 
gained  much  in  strength,  but  is  not  yet  well. 

Figure  426  shows  the  condition  of  another  of  the  eleven  patients  before  treat- 
ment by  the  X-rays.  This  case  was  considered  inoperable.  Figure  427  shows 
the  condition  after  and  during  treatment.  This  improved  condition  has  been 
maintained  for  eleven  months. 

The  four  cases  that  diseontinued  treatment  were  all  improving ;  one  could 
not  believe  that  she  had  any  serious  trouble,  though  the  growth  was  so  extensive 
as  to  include  both  breasts ;  a  second  had  another  disease  which  prevented  him 
from  coming  the  necessary  distance ;  a  third  was  sent  back  by  me  to  her  own 


APPENDIX 


703 


state  for  treatment ;  the  fourth  had  very  extensive  disease  which  seemed  to  be 
held  in  check  by  the  X-rays.  This  was  a  case  of  recurrence  after  operation,  for 
which  various  remedies  were  tried  before  the  patient,  a  woman,  was  sent  to  me 
by  Professor  Halsted  of  Johns  Hopkins  University.  Her  condition  seemed  so 
far  beyond  hope  of  rehef  from  anything,  that  neither  he  nor  I  felt  that  the  X-rays 


Fig.  424.    Case  118,  Mrs.  B.     Before  treatment.    Weight,  90  pounds.    See  also  Fig.  425. 


704 


THE    ROENTGEN    R.\YS    IN    MEDICINE   AND    SURGERY 


had  any  opportunity  for  usefulness,  but  I  consented  to  try  them  at  the  urgent 
request  of  her  devoted  husband.     (See  Fig.  428.) 

When  treatment  was  begun  there  was  extensive  induration  of  the  whole  left 
side  in  front,  which  disappeared  under  the  X-ray  exposures.     Meanwhile  a  con- 


FlG.  425.     Case  118,  Mrs.  B.     During  treatment  by  the  X-rays.     \\'eight,  1161  pounds. 

See  also  Fig.  424. 


siderable  mass  of  glands  developed  in  the  neck  and  left  side  above  the  clavicle, 
but  they  too  disappeared  under  the  action  of  the  X-rays.  The  induration  of  the 
right  side,  which  at  one  time  included  the  whole  right  breast,  also  largely  dis- 
appeared, not  more  than  one-fourth  remaining  when  treatment  was  discontinued 
because  the  patient  was  obliged  to  return  to  her  home  to  avoid  the  rigorous 
winter  chmate.  The  treatment  was  carried  on  six  months  in  all,  and  the  patient 
was  not  well  when  it  was  stopped  ;  but  there  was  great  improvement  in  her  condi- 


APPENDIX 


705 


tion  locally,  she  had  gained  in  strength  and  general  well-being,  and  had  enjoyed 

the  summer.     Six  months  later  I  learned  that  the  improvement  was  still  maintained. 

The  seven  cases  that  did  not  heal  all  improved  somewhat  locally ;  one  was 

inoperable,  and  the  rapidly  increasing  growth  involved  both  breasts  ;  the  other  six 


Fig.  426.  Case  62,  Mrs.  D.,  fifty  years  of  age.  Patient  of  Dr.  Post.  Diagnosis,  carcinoma 
of  the  breast.  Inoperable,  and  therefore  referred  to  me  for  treatment  by  the  X-rays.  Tlie  extreme 
hardness  of  the  breast  and  surrounding  parts  as  far  as  the  axilla  cannot  be  shown  in  the  cut.     The 

arm  was  bound  to  the  side.     See  Fig.  427. 

were  cases  of  recurrence  after  one  or  more  operations.  Two  of  these  latter 
were  so  extensive  as  to  be  entirely  hopeless  from  the  beginning ;  in  the  remam- 
ing  four  the  glands  were  involved,  and  metastases  had  taken  place ;  one  of  these 
has  died,  and  two  of  the  others  will  probably  not  live  long. 


7o6 


THE  ROENTGEN  RAYS  IN  MEDICINE  AND  SURGERY 


The  general  effects  of  the  X-rays  when  used  locally  in  some  forms  of  new 
growths  are  noteworthy.  The  improvement  observed  after  a  few  exposures,  of  a 
patient  with  epithelioma  of  the  nose,  for  example,  who  was  losing  strength  and 


Fig.  427.  Case  62,  Mrs.  D.  After  treatment  by  the  X-rays ;  still  under  treatment.  The  parts 
became  soft  and  her  general  condition  improved ;  and  this  improvement  has  continued  during  eleven 
months.    See  Fig.  426. 


had  the  pallor  characteristic  of  persons  suffering  from  a  carcinomatous  growth, 
was  very  striking  ;  the  pallor  largely  disappeared,  and  the  general  condition  was 
better  after  these  few  treatments.     It  would  seem  as  if  the  first  action  of  the 


APPENDIX 


70J 


X-rays  in  such  cases  was  to  put  an  end  to  the  production  of  material  which  is 
deleterious  to  the  system  as  a  whole,  and  which  is  carried  into  the  circulation. 
Certainly  some  even  of  the  small  new  growths  must  give  rise  to  products  that  act 
in  a  noxious  manner  on  the  patient,  and  the  X-rays  probably  have  the  power  of 
checking  the  production  of  these  substances. 

The  same  improvement  in  the  patient's  general  condition  is  sometimes  seen 
in  cases  of  large  inoperable  cancers  of  the  breast  where  there  is  no  rupture  of  the 


V 


Fig.  428.  Case  82.  Mrs.  A.,  fifty  years  of  age.  Clinical  diagnosis,  cancer  of  breast.  Recur- 
rence after  removal  of  left  breast.  Full  line  on  right  marks  border  of  the  induration.  Before  treat- 
ment by  the  X-rays.  Extensive  induration  of  left  side  disappeared  under  X-rays,  and  largely  on 
right  side.     Returned  to  her  home  after  six  months'  treatment,  not  well,  but  improved. 

skin.  I  have  in  mind  one  woman  who  was  transferred  to  my  care  for  treatment 
by  the  X-rays  because  her  surgeon  decided  it  was  impossible  to  do  anything  for 
her  by  operation.  She  had  the  peculiar  pallor  and  debility  that  accompany  this 
disease.  After  treatment  by  the  X-rays  her  color  and  well-being  improved,  and 
the  indurated  mass  became  softer.  The  improvement  continued,  although  the 
new  growth  appeared  in  the  other  breast,  and  had  advanced  to  a  surprising  degree 


7oS      THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

before  attention  was  called  to  it.  The  treatment  of  this  breast,  however,  was  fol- 
lowed by  the  same  improvement  as  that  of  the  first  breast,  and  the  patient,  who 
has  been  under  treatment  for  nearly  a  year,  now  says,  to  quote  her  own  expres- 
sion, "  except  for  a  slight  attack  of  rheumatism  I  feel  as  well  as  I  ever  did." 

The  history  of  this  case  shows  the  advantage  of  treating  both  breasts,  although 
only  one  may  be  involved,  as  described  on  page  677. 

Frequently  the  more  rapidly  a  new  growth  develops,  the  more  readily  will  it 
yield  to  treatment  by  the  X-rays,  except  in  cases  of  a  very  large  growth  ;  and  the 
more  indolent  and  the  longer  the  duration  of  the  new  growth,  the  more  slowly  it 
yields  to  the  X-rays. 

Operation  before  Trea/iuciit  by  the  X-Rays.  —  If  primary  cases  of  cancer  or  sar- 
coma of  the  breast  have  already  attained  considerable  size,  a  thorough  operation 
should  first  be  done,  as  a  rule,  and  then  treatment  by  the  X-rays  instituted.  The 
X-rays  should  not  be  substituted  for  surgical  interference  in  such  cases,  but  sup- 
plement it  until  further  experience  in  inoperable  cases  and  cases  that  have 
declined  operation  has  been  obtained.  The  X-rays  alone  cause  much  improve- 
ment in  some  cases,  but  most  kinds  of  new  growths,  if  of  large  mass,  diminish 
only  slowly  under  their  action. 

It  is  not  necessary  to  wait  for  the  healing  of  the  wound  after  the  operation 
before  beginning  this  treatment.  It  may  be  given  through  the  bandages,  care 
being  taken  that  no  substances  that  would  obstruct  the  rays,  such  as  iodoform, 
aristol,  oxide  of  zinc,  etc.,  have  been  used. 

X-Rays  instead  of  Operation.  —  In  certain  cases  in  which  the  patient  declines 
operation,  or  in  which,  for  any  reason,  surgical  interference  is  deemed  inadvis- 
able, or  in  inoperable  cases,  the  X-rays  may  be  of  value,  not  only  in  ameliorating 
the  symptoms,  but  also  in  checking  the  growth.  In  some  primary  cases  of  cancer 
of  the  breast,  where  the  patients  have  declined  operation,  I  have  used  the  X-rays 
at  their  earnest  solicitation.  Some  of  these  patients,  after  treatment  by  the 
X-rays  given  during  several  months,  the  breast,  axilla,  and  neck  being  exposed 
two  or  three  times  a  week,  have  remained  as  well  as  before  treatment  was 
begun,  or  have  become  better ;  in  certain  instances  the  patients  have  been  ap- 
parently well  for  more  than  fifteen  months.  We  shall,  perhaps,  find  that  in  some 
cases  of  cancer  of  the  breast  the  growth  will  not  increase  or  will  diminish  even, 
and  the  patient  will  remain  well  as  long  under  or  after  treatment  by  the  X-rays 
as  after  operation,  or  longer. 

X-Rays  or  Second  Operation. —  In  cases  of  recurrence  after  operation,  where 
the  new  growth  has  attained  some  size,  it  is  a  question  to  be  determined  for  a 
given  case  whether  another  operation  should  be  done  before  using  the  X-rays,  or 
whether  the  X-rays  alone  would  give  better  results. 

Recurrences.  —  After  surgical  treatment  of  new  growths  in  certain  situations 
in  the  body,  the  percentage  of  recurrences  is  considerable.  Therefore  the 
X-rays  should  be  used  as  an  after  treatment  in  all  forms  of  new  growths  as  soon 
as  the  condition  of  the  patient  and  the  wound  will  permit,  without  waiting  for  the 
growth  to  reappear.  Just  how  long  these  exposures  should  be  continued  in  order 
to  be  successful  we  do  not  yet  know,  but  experience  is  being  gathered  as  to  the 


APPENDIX  709 

length  of  time  that  is  necessary  to  cause  a  primary  new  growth  to  disappear  by 
means  of  the  X-rays,  and  these  data  ought  eventually  to  be  a  guide  as  to  the 
amount  of  treatment  required  to  prevent  the  recurrence  of  a  malignant  growth 
after  operation.  After  removal  of  a  breast,  the  X-rays  may  be  used  twice  a  week 
for  at  least  two  months. 

Recurrences  of  small  size  after  operation  where  no  glands  are  involved,  and 
where  there  are  no  metastases,  so  far  as  my  experience  goes,  usually  do  well  under 
treatment  by  the  X-rays.  Even  when  the  glands  are  involved,  the  place  where 
the  recurrence  has  occurred  heals  under  the  X-rays.  Evidently  the  difficulty  in 
treatment  by  the  X-rays,  as  it  has  been  by  surgical  methods,  is  to  prevent  the  ex- 
tension of  the  disease  through  the  glandular  system.  Thus  far  the  X-rays  offer  only 
partial  encouragement  for  us  to  hope  that  by  their  aid  we  may  be  able  to  cope  suc- 
cessfully with  the  glandular  involvements  accompanying  or  following  this  disease. 

The  difficulty  of  combating  cancer  becomes  greater  after  each  recurrence  or 
operation. 

Comparison  behveen  Tnaimeiit  by  X-Rays  and  an  Opciaiion  in  Cases  of 
Recurrence  after  Operation.  —  So  far  as  I  can  make  a  comparison  regarding  the 
length  of  time  during  which  the  same  patients  have  remained  well  after  operation 
and  after  treatment  by  the  X-rays  respectively,  the  results  show  that  the  interval  of 
freedom  from  recurrence  was  longer  after  the  use  of  the  X-rays  than  it  had  been 
after  an  operation  ;  or,  if  a  second  operation  had  been  performed,  the  length  of 
time  recurrence  was  delayed  was  again  in  favor  of  the  X-rays  when  they  were 
resorted  to  in  lieu  of  a  third  operation  ;  the  interval,  that  is,  was  longer  before 
a  recurrence  occurred  when  the  latter  treatment  was  used  than  that  between  a 
second  and  third  operation,  if  no  glands  were  involved,  and  it  may  ])rove  so  if 
there  is  such  involvement.  I  include  in  the  cases  on  which  this  opinion  is  based, 
breast  cases  in  which  recurrence  had  taken  place  after  one  or  more  operations, 
and  the  X-rays  had  been  used  to  treat  this  recurrence  instead  of  resorting  to  a 
second  or  third  operation.  This  comparison  is  not  based  on  a  large  number  of 
cases,  but  it  is  one  of  the  most  encouraging  experiences  regarding  X-ray  treatment 
I  have  had.     See,  for  example,  Fig.  418. 

Summary 

The  time  has  not  yet  come  to  make  too  definite  or  final  a  statement  in  regard 
to  the  value  of  the  X-rays  as  a  curative  agent  in  various  forms  of  new  growths. 
It  is  very  evident,  as  our  experience  increases,  that  different  kinds  of  new  growths 
vary  in  the  manner  in  which  they  respond  to  the  action  of  the  X-rays. 

Some  of  the  groups  of  new  growths  yield  slowly  to  the  action  of  the  X-rays, 
and  a  certain  percentage  of  them  do  not  yield ;  while  in  other  groups  response 
to  the  X-rays  is  rapid,  and  nearly,  if  not  quite  all,  in  these  groups  yield  to  them. 

External  New  Groiuths.  —  Further  experience  may  show  us  that  most  of  the 
small  external  forms  of  cancer  can  be  better  treated  by  the  X-rays  than  by  surgi- 
cal means  ;  this  point  is,  of  course,  not  yet  established.  In  the  extreme  cases, 
which  are  beyond  surgical  relief,  the  X-rays,  if  used  intelligently,  may  prolong  life 
or  ameliorate  suffering:  in  some  though  not  in  all  instances.     The  chief,  if  not  the 


7IO     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

only  field  for  the  surgeon,  inay,  within  a  few  years,  be  shown  to  lie  in  those  cases 
which  are  intermediate  between  the  small  forms,  on  the  one  hand,  and  the  in- 
operable ones  on  the  other.  Some  cases  will  doubtless  be  most  successfully  and 
quickly  reheved  by  combining  the  two  methods  of  treatment,  the  growth  being 
first  removed,  as  far  as  possible,  and  then  treatment  by  the  X-rays  instituted. 

Most  forms  of  superficial  new  growths  heal  under  the  X-rays.  It  seems  prob- 
able that  this  method  will  yield  as  good  results  as  operation,  but  only  time  and 
careful  comparison  can  determine  this  question.  Should  they  prove  to  be  no 
better  than  operation,  their  painlessness  will  give  them  a  great  advantage,  in  that 
patients  will  come  earlier  for  treatment. 

Breast  Cancer.  —  The  X-rays  may  be  used  in  inoperable  cases  of  breast 
cancer,  to  ameliorate  suffering  and  prolong  life. 

They  should  be  used  as  a  post-operative  treatment. 

They  should  be  used  early  in  cases  of  recurrence  after  operation. 

In  cases  in  which  the  growth  is  of  some  size,  an  operation  should  first  be 
done  ;  if  operation  is  declined,  the  X-rays  may  be  used.  Some  of  my  cases 
have  been  improved  in  general  health  and  remained  well  for  more  than  a  year, 
and  growths  of  considerable  size  have  ceased  to  increase,  or  have  become 
smaller,  under  the  X-rays. 

In  primary  cases,  or  in  recurrences  in  which  the  growth  is  not  large,  the  hard 
masses  in  some  cases  soften  under  the  X-rays.  Drainage  might  then  be  obtained 
by  the  burning  action  of  the  X-rays  in  a  small  spot  or  by  incision  with  a  knife. 

Recurrences  in  the  original  site,  and  where  the  glands  are  not  affected, 
usually  do  well  under  the  X-rays,  if  metastasis  does  not  take  place. 

INTERNAL  FORMS  OF  CANCER 

At  present  the  practitioner  is  not  justified  in  promising  that  the  X-rays  will 
cause  deep-seated  new  growths  to  heal,  but  they  do  afford  relief  in  some  cases, 
either  after  operation,  or  w^here  operation  is  not  practicable,  and  sometimes  still 
better  results  have  been  reported,  especially  in  cancer  of  the  uterus. 

RolHns,'  in  order  to  learn  whether  or  not  the  X-rays  would  affect  cell  growth 
in  the  interior  of  the  body,  with  a  view  to  their  effects  in  internal  cancer,  made  a 
series  of  careful  experiments  on  guinea  pigs.  To  exclude  any  electrical  effects, 
the  guinea  pigs  were  placed  in  a  grounded  Faraday  chamber,  that  is,  in  a  closed 
metallic  chamber  that  was  hung  by  silken  cords  inside  another  metallic  chamber. 
The  walls  of  the  two  chambers  that  faced  the  tube  were  made  of  aluminum  .26 
millimetre  thick,  and  the  walls  on  the  side  away  from  the  tube  had  windows  of 
iron  wire  gauze  in  order  that  air  might  be  admitted.  The  tube  was  placed  out- 
side the  Faraday  chamber,  and  its  target  was  14  centimetres  from  the  guinea 
pigs.  The  X-rays  were  obliged  to  go  through  two  sheets  of  aluminum  before 
they  could  reach  the  animals,  one  of  which  was  connected  with  the  earth  by 
means  of  a  small  metal  wire  ;  and  yet  loss  of  hair,  paralysis,  abortion,  burns,  or 

"^Boston  Medical  and  Surgical  Journal,  February  14  and  28,  March  28,  1901,  and  Janu- 
ary 9,  1902. 


APPENDIX 


711 


death  could  be  produced,  if  the  exposures  were  long  enough,  or  death  could  be 
produced  without  causing  a  burn.  As  a  control  other  guinea  pigs  were  placed  in 
the  Faraday  chamber,  but  were  not  exposed  to  the  X-rays,  and  kept  there  for 
the  same  length  of  time  as  those  that  were  so  exposed.  These  guinea  pigs 
remained  well  and  produced  young.  Both  classes  of  guinea  pigs  were  kept  in 
the  same  pen  and  received  the  same  care  and  food. 

Skinner  ^  reports  thirty-three  cases  of  cancer  that  he  divides  into  five  groups, 
which  he  has  had  under  treatment  during  the  preceding  nine  months,  and  some 
of  these  come  under  the  head  of  internal  cancer. 

The  first  group  consisted  of  ten  cases,  in  which  different  deep-seated  localities 
•were  involved  and  terminated  fatally ;  the  second  group,  of  four  cases  in  which 
bony  tissue  was  affected  ;  the  third  group,  of  eight  intra-abdominal  cases,  which 
were  still  under  treatment  when  reported  ;  the  fourth,  of  ten  mammary  cancers ; 
and  the  fifth,  of  one  case  of  sarcoma  of  the  neck.  Restates,  without  designat- 
ing the  groups  that  there  was  apparent  complete  disappearance  of  the  malig- 
nant process  in  three  cases ;  gradual  reduction  in  the  size  of  the  growth  in 
thirteen  cases,  with  good  prospects  of  ultimate  cure  ;  that  twelve  cases  were 
temporarily  benefited ;  that  two  experienced  no  benefit  whatever ;  and  that 
in  three  the  treatment  was  discontinued  by  the  patients  after  two  or  three 
exposures. 

Pain.  —  Permanent  relief  from  pain  was  obtained  in  fourteen  cases  ;  complete 
temporary  relief  in  two  ;  partial  relief  in  eight ;  and  no  relief  whatever  in  four. 
In  five  cases  there  was  no  pain. 

Hemorrhage. — The  amount  of  hemorrhage  was  lessened  in  eight  cases,  and 
uninfluenced  in  one.     In  twenty-four  there  was  no  hemorrhage. 

Toxcemia.  —  Evidence  of  systemic  toxaemia  was  observed  in  fourteen  cases 
at  some  time  during  the  treatment. 

Skinner  states  that  all  of  these  thirty-three  cases  were  inoperable,  because  of 
the  advanced  stage  of  the  disease,  and  he  draws  from  the  results  he  obtained  the 
conclusion  that  the  X-rays  are  capable  of  retarding  the  progress  of  the  disease 
in  cases  of  deeply  seated  cancer,  even  if  they  cannot  save  life ;  that  in  a  certain 
proportion  of  these  cases  the  X-rays  can  apparently  restore  the  patient  to  perfect 
health  ;  that  in  a  small  number  of  deep-seated  cases  of  malignant  growth  the 
X-rays  seem  to  have  no  eff"ect ;  that  chills,  rise  of  temperature,  etc.,  indicating 
systemic  toxemia,  not  infrequently  accompany  the  treatment  of  malignant 
growths  by  the  X-rays,  and  that  this  condition  is  probably  due  to  a  liberation  of 
toxin,  "  the  formation  of  which  is  probably  dependent  upon  retrogressive  meta- 
morphosis, occurring  in  masses  of  tissue,  which  have  become  too  deeply  involved 
in  the  malignant  change  to  be  susceptible  of  regeneration."  Skinner  thinks  this 
autoinfection  is  capable  of  being  carried  so  far  as  to  destroy  the  patient,  and 
therefore  deems  it  wise  to  interrupt  the  treatment  when  systemic  toxremia  first 
appears,  in  order  to  give  the  organism  an  opportunity  to  throw  off"  the  injurious 
accumulation. 

1 «  X-Light  in  Therapeutics,"  Medical  Record,  December  17,  1902,  pp.  1007-1013. 


712      THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

One  case^  that  Skinner  describes  is  of  special  interest.  The  growth  was  in 
the  left  broad  ligament,  and  was  said  to  be  malignant  and  inoperable,  but  no 
microscopical  diagnosis  was  matle.  It  was  accompanied  by  ascites,  and  frequent 
tappings  were  necessary.  The  patient  was  first  treated  by  the  X-rays  January  27, 
1902,  and  three  days  later  two  gallons  of  fluid  were  withdrawn  from  the  abdo- 
men by  a  canula.  During  the  next  month  eleven  X-ray  exposures  were  given^ 
and  the  soreness  on  palpation  was  considerably  lessened,  and  the  general  condi- 
tion improved.  The  patient  was  then  tapped  again,  and  a  gallon  and  a  quarter 
of  fluid  removed.  The  weight  at  this  time  was  128^  pounds.  X-ray  exposures 
were  given  three  times  a  week  for  two  months  more.  The  fluid  did  not  increase 
to  any  extent  during  this  period,  the  patient  continued  to  feel  better,  and  her 
weight  increased  to  i4o|-  pounds.  When  reported  the  exposures  were  being 
made  on  an  average  three  times  a  week,  the  fluid  had  noc  reaccumulated,  the 
growth,  so  far  as  examination  showed,  had  decreased  in  size,  and  the  general 
health  was  excellent. 

Dr.  Thomas  Bryant-  reports  a  case  of  cancerous  stricture  of  the  rectum  in  an 
old  man,  in  which  good  results  had  been  obtained  by  the  application  of  the 
X-rays  through  the  perineum.  After  this  treatment  the  patient  could  pass  his 
dejections  without  pain,  and  the  finger  could  be  introduced  through  the  stricture 
without  force. 


To  use  the  X-rays  successfully  in  the  treatment  of  new  growths,  the  apparatus- 
should  be  of  the  best  and  well  under  the  control  of  the  practitioner.  The  action 
of  the  X-rays  on  the  growths  must  be  most  carefully  watched,  and  the  treatment 
be  used  in  a  way  to  promote  healing  and  to  avoid  over-stimulation,  which  may 
cause  extension  of  the  growth,  or  toxaemia. 

The  problem  of  the  use  of  the  X-rays  is  still  in  the  stage  of  development  ; 
later  we  shall  be  better  able  to  assign  to  them  such  cases  as  they  can  ameliorate, 
delay,  arrest,  or  heal. 

Keloid  and  Hvpertrophied  Scar  Tissue 

Mr.  L.  Herschel  Harris  ''  reports  one  case  in  whicli  hvpertrophied  scar  tissue, 
formed  after  an  operation  for  tubercular  glands  of  the  neck,  was  removed  by 
intermittent  treatment  with  the  X-rays  during  three  months. 

Lupus  Vulgaris 

In  this  disease  it  is  necessary  that  the  treatment  should  be  carried  out  for  a 
long  time,  and  more  vigorously  than  in  many  other  diseases  of  the  skin,  and  the 

■^  "  X-Light  in  the  Treatment  of  Cancer,"  American  X-Kay  Journal,  November,  1902, 
pp.  1219-1234. 

■■^  British  Medical  Journal,  October  25,  1902,  pp.  1 302-1 303. 

3  "Therapeutics  of  the  Roentgen  Rays,"  The  Australasian  Medical  Gazette,  September  20, 
1902,  pp.  44M50. 


APPENDIX  713 

percentage  of  recoveries  is  not  so  great  as  in  some  other  skin  diseases.  It  is  an 
advantage  to  begin  tlie  treatment  early,  and  it  does  not  seem  to  answer  as  well 
when  operative  measures  have  been  previously  employed.  The  cosmetic  results 
are  excellent.  Dr.  Thurston  Holland  ^  recommends  that  the  X-rays  should  be 
used  before  any  other  method  is  adopted,  not  only  in  bad  cases  of  long  continu- 
ance, but  more  especially  in  cases  that  are  in  an  early  stage.  Schiff,-  on  the 
contrary,  considers  extirpation  and  transplantation  the  ideal  method  for  circum- 
scribed, accessible,  little  foci,  and  that  the  X-rays  should  be  used  for  the  extensive, 
deeply  ulcerated  processes  that  attack  the  mucous  membrane  and  inaccessible 
parts,  and  are  looked  upon  as  inoperable. 

Holland  reports  two  cases  of  lupus  vulgaris  of  five  years'  duration  that  had 
been  scraped  and  cauterized  before  treatment  by  the  X-rays,  that  are  of  interest. 
The  ulcerated  lupus  patch  in  the  first  case,  involving  the  lobe  of  the  left  ear  and 
extending  from  there  to  the  left  side  of  the  chin,  was  given  seventeen  exposures 
of  fifteen  minutes  each  ;  there  was  a  slight  recurrence  after  a  lapse  of  nearly  two 
years,  and  six  more  exposures  of  ten  minutes  each  were  given.  The  ulcerated 
lupus  patch  in  the  second  case,  a  little  larger  than  a  halfpenny,  was  given  six 
exposures  of  ten  minutes  each. 

Dr.  Clarence  A.  Greenleaf  ^  believes  that  cases  which  have  not  been  subjected 
to  surgical  treatment  recover  rapidly  on  exposure  to  the  X-rays,  but  that  if  they 
have  received  the  former  treatment  before  that  by  X-rays,  recovery  is  slow  in  pro- 
portion to  the  amount  of  this  previous  surgical  interference.  In  one  case  which 
he  reports,  where  there  had  been  no  surgical  treatment,  good  results  were  obtained 
by  twelve  exposures  to  the  X-rays.  He  points  out  the  importance  of  hygienic 
surroundings  and  the  good  general  condition  of  the  patient  to  the  ultimate  result. 

Lupus  Erythematosus 

Two  more  cases  of  lupus  erythematosus,  in  addition  to  those  given  in  the 
body  of  the  book,  may  be  of  interest  as  strengthening  the  evidence  of  the  good 
effect  of  treatment  by  the  X-rays  in  this  disease. 

Dr.  Richard  F.  Woods'*  reports  the  following  case,  that  had  been  increasing 
for  four  years,  but  was  cured  by  five  exposures  to  the  X-rays  of  ten  minutes  each, 
given  twice  a  week  :  — 

M.  D.,  thirty-two  years  of  age.  The  patient  noticed  a  small  pimple  on  her 
face,  which  increased  in  size,  bled  quite  freely  at  times,  and  caused  some  pain. 
Two  years  previous  to  treatment  by  the  X-rays,  the  patient  had  ajiplied  various 
ointments  and  taken  medicine  internally  without  obt.iining  good  results.     July  12, 

1  "The  Treatment  of  Lupus  by  the  X-Rays,"  Liverpool  Medico-Chirurgual  Journal,  March, 

1901,  pp.  87-92. 

2"Der   Gegenwartige    Stand    der   Roentgen-Therapie,"    Klinisch-therapcutisclie    Wochen- 

schrift,  1901,  No.  27,  July  7,  pp.  883-887. 

3  "The  Therapeutic  Value  of  the  X-Ray  in  Lupus  Vulgaris,"  Buffalo  Medical  Journal, 
Octolier,  1901,  pp.  189-193. 

*  "A  Case  of  Lupus  Erythematosus  cured  by  the   X-Rays,"  American  Journal  of  Medical 

Sciences,  September,  1901,  pp.  834-836. 


714     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

1 90 1,  the  growth,  about  the  size  of  a  half  dollar,  was  slightly  raised,  of  a  bright 
reddish  color,  and  its  centre  was  partially  covered  with  scales ;  the  mouths  of 
the  sebaceous  glands  were  somewhat  altered,  and  the  follicular  orifices  were 
enlarged  and  filled  with  hardened  sebaceous  matter. 

The  improvement  was  remarkable  after  the  second  exposure  to  the  X-rays, 
and  went  on  so  rapidly  that  a  sixth  treatment  was  found  unnecessary. 

Dr.  James  Startin '  reports  a  well-marked  case  of  butterfly  lupus  erythematosus 
extending  over  the  bridge  of  the  nose  on  to  both  cheeks  in  a  woman  thirty  years 
of  age.  Dr.  Startin  used  at  first  various  applications  —  salicylic  collodion,  etc.  — 
with  some  good  results,  but  progress  was  slow.  He  then  applied  the  X-rays  at 
intervals  of  three  days  ;  the  results  were  good  ;  after  six  applications  cicatrization 
had  taken  place. 

Leprosy 

Sequeira  -  reports  one  case  of  nodulated  leprosy  of  the  skin  that  has  shown 
marked  improvement,  the  hard  masses  softening  and  becoming  flat. 

Scholtz''  reports  that  he  obtained  no  marked  results  in  two  cases  of  leprosy 
treated  by  the  X-rays,  and  that  de  la  Camp  obtained  none. 

Mycosis  Fungoides 

Scholtz  ■*  reports  three  cases  of  mycosis  fungoides  treated  by  the  X-rays.  In 
two  of  these  cases  the  treatment  was  so  energetic  as  to  produce  a  superficial 
necrosis,  but  under  its  use  not  only  did  the  premycosic  patches  disappear,  but 
also  the  tumors.     New  foci,  however,  appeared  in  other  parts  of  the  body. 

Norman  Walker^  also  reports  a  case  treated  by  Allan  Jamieson  with  very 
marked  improvement. 


Goitre  with  Enlarged  Thyroid 

In  goitre  with  enlarged  thyroid,  the  X-rays  seem  to  cause  some  improvement, 
but  I  do  not  find  that  much  has  been  published  on  this  subject,  and  my  own 
experience  is  too  limited  to  justify  me  in  doing  more  than  encourage  others  to 
try  them  in  this  disease  in  order  to  ascertain  whether  there  may  or  may  not  be 
certain  cases  in  which  they  may  be  of  assistance.  The  case  of  acne  referred  to 
on  page  671  that  was  treated  by  Campbell  with  the  X-rays,  and  in  which  coinci- 
dently  with  the  healing  of  this  disease  a  goitre  also  largely  disappeared,  is  of  inter- 
est in  this  connection. 

J  "On  X-Rays  in  the  Treatment  of  Lupus  and  Rodent  Ulcer,"  The  Lancet,  July  20,  1901, 
pp.  144-145- 

2  British  Medical  Journal,  September  28,  1901,  p.  851. 

^"Ueber  den  Einfluss  d.  Roentgenstrahlen  a.  d.  Haut  in  gesundem  u.  krankem  Zustande," 
Arch.  f.  Dermal,  u.  Syphilis,  Vol.  59,  1902,  pp.  443-444. 

*  Ibid. 

^  British  Medical  Journal,  October  25,  1902,  p.  1319. 


APPENDIX 


Pulmonary  Tuberculosis 


715 


Dr.  Samuel  Beresford  Childs  ^  reports  a  case  of  pulmonary  tuberculosis  treated 
by  the  X-rays.  The  patient  consulted  Dr.  Childs  May  24,  1902,  about  a  year 
after  her  arrival  in  Colorado.  She  was  coughing  and  expectorating  freely  in  the 
morning  and  after  each  meal.  Tubercle  bacilli  were  present  in  the  sputum. 
The  weight  was  about  normal ;  no  rise  in  temperature  was  detected.  P)Oth 
apices  were  affected,  and  the  left  was  consolidated  to  the  second  rib.  Anteriorly 
prolonged  expiration  and  bronchial  breathing  were  present  in  this  area,  and 
moist  rales  could  be  heard  below  the  clavicle.  Moist  rales  were  also  detected 
posteriorly  at  the  superior  angle  of  the  scapula  in  both  the  right  and  left  lung. 

X-i-a\  exposures  were  begun  May  24,  1902,  and  seventy-six  were  given 
between  that  date  and  September  26,  1902,  the  chest  and  back  being  exposed 
on  alternate  days.  The  rays  had  sufficient  penetration  to  make  the  contents  of 
the  thorax  plainly  visible  on  the  fluorescent  screen.  The  signs  of  moisture  had 
disappeared  from  the  lungs  September  26,  1902,  but  the  consolidation  and 
bronchial  breathing  were  still  present.  Nine  weeks  after  the  exposures  had  been 
given,  namely,  August  6,  the  expectoration  had  ceased  and  did  not  recur. 

Chronic  Tuberculous  Peritonitis 

Freund "-  states  that  Ausset  and  Bedard  report  a  case  of  chronic  tuberculous 
peritonitis  treated  by  the  X-rays.  The  exposures  were  given  daily  and  were  of 
thirty  minutes'  duration,  the  tube  being  from  20-13  centimetres  distant.  After 
fifty  exposures  the  ascitic  fluid  had  been  absorbed,  the  hard  tuberous  masses, 
which  could  be  felt  in  the  abdomen,  had  disappeared,  and  the  general  well-being 
of  the  patient  had  improved.  Two  years  later,  they  reported  a  second  case  with 
similar  favorable  results. 

Adenitis 

In  some  forms  of  adenitis,  especially  tuberculous  cervical  adenitis,  the  X-rays 
cause  the  glands  to  disappear,  and  as  in  this  disease  the  patient  does  not  sufi"er 
by  delaying  operative  treatment,  I  think  that  the  X-rays  should  be  given  a  trial, 
especially  in  the  case  of  girls,  where  an  operation  would  leave  an  unsightly  scar. 
In  cases  where  the  X-rays  give  relief,  some  improvement  should  be  expected 
within  a  month  or  six  weeks,  but  all  cases  do  not  yield  to  this  treatment. 

In  some  of  my  cases  of  tuberculous  adenitis,  even  when  the  glands  were  of 
great  size,  the  improvement  has  been  satisfactory. 

Tuberculous  Sinuses 

Tuberculous  Sinuses  of  the  Neck.  —  Dr.  F.  M.  Briggs  has  had  two  cases  of 
tuberculous  sinuses  of  the  neck  that  have  been  benefited  by  treatment  with  the 
X-rays,  of  which  he  has  kindly  given  me  notes. 

The  first  was  that  of  a  boy  about  fourteen  years  of  age  who  gave  a  history  of 

1  "  Cases  illustrating  the  Therapeutic  Uses  of  the  Roentgen  Kays,"  Medical  Xeivs,  Janu- 
ary 24,  1903,  p.  149. 

-  "  Grundriss  der  Gesammten  Radiotherapie  fiir  Praktische  Arzte,"  1903,  p.  245. 


7i6      THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

long  standing,  freely  suppurating  cervical  adenitis  on  both  sides  of  the  neck,  and 
of  eight  months'  treatment  and  operations  at  different  hospitals.  When  Dr. 
Briggs  first  saw  him  he  had  a  sinus  opening  on  both  sides  of  the  neck,  and  fluid, 
injected  into  the  opening  on  one  side  issued  from  that  of  the  other.  Dr.  Briggs 
referred  the  case  to  Dr.  S.  W.  Allen  for  treatment  by  the  X-rays.  After  six 
exposures  the  opening  on  one  side  had  closed,  and  there  was  only  a  small 
amount  of  daily  discharge  from  that  on  the  other.  The  patient  was  siill  under 
treatment  and  improving. 

The  second  case  was  that  of  a  boy  of  about  eight  years  of  age  who  had  had 
a  daily  discharge  from  a  sinus  on  one  side  of  the  neck  near  the  ear,  for  nineteen 
months,  during  which  time  he  had  been  under  constant  treatment  without  avail. 
Dr.  Briggs  referred  this  case  to  Dr.  C.  C.  Simmons,  and  after  two  exposures  to 
the  X-rays  by  him  the  sinus  stopped  discharging.  The  patient  has  reported 
once  a  week  since  the  sinus  has  closed,  and  it  has  not  reopened. 

Dr.  Samuel  Beresford  Childs  ^  reports  a  case  of  tuberculous  glands  of  the  right 
side  of  the  neck,  which  he  treated  by  the  X-rays,  that  was  referred  to  him  by 
Dr.  S.  G.  Bonney.  In  this  patient  the  glands  at  the  posterior  border  of  the 
sterno-mastoid  muscle  in  the  upper  half  of  the  neck  were  much  enlarged, 
and  a  mass  of  two  or  three  glands  were  matted  together  and  projected  below 
and  behind  the  lobe  of  the  ear.  The  chain  in  front  of  the  trapezius  was  also 
enlarged.  This  condition  of  the  glands  had  existed  for  six  years,  slight  variations 
in  size  occurring  according  to  the  general  health  of  the  patient. 

Twenty-four  X-ray  exposures  were  given  to  the  glands  in  the  upper  part  of  the 
neck  and  sixteen  to  the  lower  chain  in  front  of  the  trapezius  between  May  2  and 
June  16,  1902.  On  this  latter  date  the  patient  was  examined  by  Dr.  Bonney, 
who  reported  the  glands  one-half  smaller.  The  exposures  were  then  discon- 
tinued, as  the  patient  left  the  city  for  the  summer.  The  glands  continued  to 
diminish  in  size,  and  when  the  case  was  reported,  nearly  four  months  after 
cessation  of  treatment,  were  scarcely  perceptible. 

Old  Ulcerations 

Sjogren  and  Sederholm-  found  that  old  ulcerations  were  favorably  influenced 
by  the  X-rays,  in  that  fresh  granulations  arose  which  were  followed  by  healing. 

Dr.  Taylor'^  reports  that  "a  further  proof  of  the  remediable  effect  of  the  rays 
in  stimulating  the  growth  of  epithelium  was  afforded  by  the  following  case."  A 
small  boy  had  been  burned  on  the  left  arm  near  the  elbow  joint.  His  arm  had 
been  neglected,  and  where  any  healing  had  taken  place  the  scar  was  hard  and 
fibrous,  and  contractions  seemed  probable.  Dr.  Taylor  applied  the  X-rays,  and  the 
unhealed  portions  of  the  ulcer  healed  rapidly ;  there  was  a  soft  and  flexible  scar, 
and  the  child  had  a  serviceable  movement  of  the  arm. 

^  "  Cases  illustrating  the  Therapeutic  Uses  of  the  Roentgen  Rays,"  Medical  Xezas,  January  24, 
1903,  p.  146. 

^  "  Beitrag  zur  therapeutischen  Verwertung  der  Roentgenstrahk-n,"  Foitschiitte  a.  d.  Geb. 
der  Roentgenslr.,  B.  IV,  H.  4,  pp.  145-170. 

3  British  Medical  Journal,  September  28,  1901,  pp.  852-853. 


APPENDIX  -17 

Hodgkin's  Disease 

I  have  treated  three  patients  with  Hodgkin's  disease  by  means  of  the  X-rays. 

The  first  case,  J.  M.,  a  man  twenty-one  years  old,  was  given  in  the  last  edition. 
He  had  had  the  disease  one  year  when  treatment  by  the  X-rays  was  begun,  and  he 
improved  with  rapidity.  The  glands  diminished  in  size,  his  pallor  disappeared, 
his  strength  increased,  and  in  every  way  progress  was  most  satisfactory.  After 
the  lapse  of  seven  months  improvement  ceased,  and  during  the  following  eight 
weeks  the  glands  grew  larger.  He  became  anremic,  lost  m  strength,  suffered  from 
distress  in  the  stomach  and  dyspnoea;  and  it  became  evident  that  the  X-ray 
treatment  was  of  little  or  no  avail.  Exposures  had  been  given  during  all  these 
months,  three  times  a  week,  usually  for  ten  minutes,  with  the  tube  at  a  distance 
of  about  20  centimetres,  over  each  of  the  affected  glands.  Over  the  spleen 
the  exposures  were  of  longer  duration.  He  died  nine  months  after  the  treat- 
ment was  begun.  The  X-rays  caused  improvement  and  probably  prolonged 
his  life. 

The  second  case,  a  man  twenty-three  years  old,  improved  very  much,  but  went 
during  his  improvement  to  Louisiana,  and  I  have  not  been  able  to  hear  from  him 
since. 

The  third  case,  a  woman  sixty-two  years  old,  gave  up  the  treatment,  as  I  did 
not  feel  justified  in  promising  her  ultimate  success  ;  but  she  has  recently  returned 
desiring  further  treatment. 

We  may  find  that  the  X-rays  will  be  the  means  of  relieving  patients  with  this 
disease  ;  how  much  more  they  can  do  remains  for  further  experience  to  determine. 
Improvement  at  first  is  certainly  rapid  and  marvellous. 

Dr.  Pusey'  reports  two  cases  of  Hodgkin's  disease  which  he  has  under  treat- 
ment by  the  X-rays. 

The  first  was  a  boy  four  years  of  age.  In  August,  1901,  Dr.  Ochsner  made  a 
diagnosis  of  Hodgkin's  disease  and  removed  the  cervical  glands  on  the  rii^hi  side. 
On  September  1 1  he  referred  the  case  to  Dr.  Pusey  for  the  treatment  of  the 
glands  on  the  left  side,  which  were  as  large  as  a  fist,  by  the  X-rays.  After  two 
months'  treatment  these  glands  were  reduced  to  the  size  of  an  almond.  From 
November,  1901,  up  to  the  time  the  case  was  reported  on  by  Dr.  Pusey,  the  boy 
was  given  intermittent  treatment  by  the  X-rays. 

Dr.  Pusey-  made  a  further  report  on  this  case,  namely,  on  April  12,  1902,  and 
stated  that  no  change  had  taken  place. 

The  second  patient  was  a  man  fifty  years  of  age  who  had  an  enlargement  of 
the  axillary  and  epitrochlear  glands  of  the  right  side.  The  diagnosis  of  Hodg- 
kin's disease  was  made  by  Dr.  Mc Arthur,  and  the  patient  was  treated  for  some 
time  with  parenchymatous  injections  of  arsenic,  in  spite  of  which  the  tumors 
steadily  increased  in  size.  On  November  i,  1901,  when  the  epitrochlear  gland 
was  almost  as  large  as  a  goose  egg  and  very  hard,  Dr.  Pusey  subjected  it  to  the 
X-rays.     Within   a   month  it   was   about  one-third   its   previous   size,  and   when 

^  Journal  of  American  Medical  Association,  ]!inMZ.ry  iS,  1902. 

'^  Journal  of  Amej-ican  Medical  Association,  April  12,  1902,  pp.  917-919- 


7l8     THE    ROENTGEN    RAYS    IN    MEDICINE    AND    SURGERY 

reported  on  was  about  as  large  as  an  olive,  and  quite  soft.  Meanwhile  the 
axillary  gland,  which  was  being  treated  with  the  arsenic  injections,  showed  no 
change.  On  December  i8,  at  Dr.  Mc Arthur's  suggestion,  Dr.  Pusey  began  to 
make  exposures  of  this  gland,  which  was  as  large  as  a  child's  head  and  interfered 
with  the  motion  of  the  arm,  to  the  X-rays.  Dr.  Pusey  reports  that  the  patient 
thinks  it  softer  and  smaller,  and  says  that  he  can  now  play  billiards,  which  of  late 
he  had  been  unable  to  do. 

In  a  later  report  Dr.  Pusey^  states  that  by  January  20,  1902,  almost  all  the 
axillary  swelling  had  disappeared,  and  had  not  returned  when  the  report  was 
made,  namely,  in  April,  1902.  The  general  condition  of  the  patient  had  also 
greatly  improved. 

Disease  of  Cornea 

Some  time  since  I  suggested  to  my  friend.  Dr.  Walter  B.  Lancaster,  the 
possibility  of  using  the  X-rays  in  the  treatment  of  certain  affections  involving  the 
cornea,  and  asked  him  if  he  would  send  me  some  cases.  Dr.  Lancaster  kindly 
consented  to  do  so,  and  sometime  later  sent  me  two  patients,  but  expressed  him- 
self as  sceptical  of  any  good  results  following  the  treatment.  I  exposed  both 
these  patients  to  the  X-rays,  and  some  improvement  resulted  in  each  case,  but  I 
will  consider  one  only  in  detail,  as  the  other  was  obliged  to  return  to  his  home 
in  Nova  Scotia  before  a  satisfactory  number  of  exposures  had  been  made. 

Case  I.  Charles  F.,  forty-eight  years  of  age.  History  of  gonorrhceal 
ophthalmia  twenty  months  previously. 

Condition  %vhen  Treatment  by  the  X-Rays  was  Begun.  —  Dr.  Lancaster  found 
that  in  the  left  eye  there  was  a  semicircular,  dense,  flat  leucoma  in  the  lower  half 
of  the  cornea,  shading  off  gradually  in  the  upper  half,  and  leaving  above  the  dis- 
eased portion  a  crescent  of  clear  cornea  2-3  millimetres  wide,  and  below  it  a 
strip  \—\  millimetre  wide  ;  that  the  pupil  dilated  but  httle  with  mydriatic,  on 
account  of  an  extensive  adhesion,  so  that  vision  was  the  same  with  and  without 
atropine.  The  patient  could  count  his  fingers  at  a  distance  of  25  to  30  centime- 
tres and  stated  that  there  had  been  no  improvement  in  the  eye  for  months. 

Method  of  Treatment.  —  I  raised  the  upper  lid  of  the  eye  by  sticking  one  end 
of  a  strip  of  surgeon's  plaster  to  it  and  the  other  end  to  the  forehead.  I  then 
suspended  a  disk  of  glass  about  4  centimetres  in  diameter,  in  the  centre  of  which 
there  was  a  hole  3-4  millimetres  in  diameter,  in  front  of  the  eye  so  that  the  open- 
ing came  opposite  the  area  I  desired  to  expose  to  the  X-rays.  The  disk  was 
held  by  a  thread  which  passed  through  its  opening  and  was  fastened  to  the 
surgeon's  plaster  on  the  forehead.  The  diaphragm  used  in  the  tube  holder  had 
an  opening  about  i^  centimetres  in  diameter,  and  this  opening  was  brought  oppo- 
site the  aperture  in  the  disk  and  only  3  centimetres  away  from  it.  The  exposures 
were  made  once  a  week  for  three  months  and  twice  a  week  for  two  months, 
lasting  usually  about  ten  minutes.  It  was  necessary,  of  course,  to  proceed  with 
great  caution  when  exposing  the  eye  to  the  X-rays. 

'^  Journal  of  American  Medical  Association,  April  12,  1902,  pp.  917-919. 


APPENDIX  yig 

At  the  end  of  this  five  months  I  sent  the  patient  to  see  Dr.  Lancaster,  and  he 
reported  that  the  patient  could  count  his  fingers  at  a  distance  of  60  centimetres 
instead  of  25-30  centimetres  as  before ;  that  the  greatest  gain  was  in  the  appear- 
ance of  the  scar,  which  was  smaller,  smoother,  and  less  dense  than  before.  To 
eliminate  error  in  this  examination,  the  vision  was  tested  without  atropine  and 
after  atropine  had  been  in  the  eye  for  twenty-four  hours. 

I  have  satisfied  myself  in  other  cases  that  it  is  quite  possible  to  expose  the 
conjunctiva  to  the  X-rays  for  therapeutic  purposes,  and  this  patient  shows  that  it 
is  practicable  to  expose  the  cornea  to  them.  I  hope  to  have  the  opportunity  of 
pursuing  these  studies  farther  with  Dr.  Lancaster,  for  the  number  of  cases  in 
which  vision  is  impaired  or  lost  through  a  diseased  cornea  is  large ;  there  seems 
to  be  no  danger  in  the  method  if  it  is  carried  out  with  extreme  care,  and  it  is  pos- 
sible that  some  among  the  many  patients  suffering  from  disease  of  the  cornea  may 
be  relieved.     Rodent  ulcer  of  the  cornea  would  perhaps  yield  to  such  treatment. 

Foreign  Bodies 

Dr.  W.  M.  Sweet  ^  gives  further  results  concerning  the  use  of  the  X-rays 
(see  page  537)  in  locating  foreign  bodies  in  the  eye.  He  has  used  them  in 
one  hundred  and  two  cases  to  determine  the  absence  or  presence  of  such  bodies 
in  the  eyeball  or  surrounding  tissues ;  in  sixty-five  of  these  a  foreign  body  was 
shown  ;  in  thirty-seven  the  result  of  the  examination  was  negative.  So  far  as 
these  examinations  were  verified  by  the  extraction  of  the  foreign  body  or  after 
enucleation,  the  accuracy  with  which  the  X-rays  can  locate  a  foreign  substance 
was  demonstrated.  His  method  of  localization  is  the  "  triangulation  of  the  shadow 
of  the  foreign  body  from  two  different  positions  in  relation  to  the  shadows  on  the 
photographic  plate  of  two  known  points  so  that  accuracy  must  result"  if  proper 
care  is  used.  Dr.  Sweet  instances  one  case  in  which  the  knife  struck  the  steel 
in  making  the  scleral  opening  at  the  indicated  point,  and  another  in  which  it  was 
possible  to  show  that  the  body  was  partly  imbedded  in  the  optic  nerve,  from  which 
it  was  removed  by  forceps.  Dr.  Sweet  concludes  that  the  X-rays  offer  the  most 
certain  method  for  detecting  and  locating  foreign  bodies  in  the  eye. 

Dr.  Fox  thinks  that  it  is  much  easier  to  locate  a  foreign  body  by  means  of 
the  apparatus  he  has  devised  than  by  Dr.  Sweet's  localizer.  His  apparatus  is 
as  follows  :  — 

Localizer  for  Determining  Foreign  Bodies  in  the  Eye.  —  Dr.  L.  \\'ebster  Fox  - 
of  Philadelphia  describes  a  localizer  he  has  devised  for  determining  the  position 
of  foreign  bodies  in  the  eye.  It  consists  of  an  oval  band  of  gold  or  silver  0.75 
millimetre  in  width,  so  curved  as  to  conform  to  the  outline  of  the  eye,  and 
crossed  in  front  by  two  gold  strands  at  right  angles  to  each  other,  thus  dividing 
the  oval  band  into  quadrants.     This  localizer  is  adjusted  directly  to  the  surface 

1  "  Results  of  X-Ray  Diagnosis  and  of  Operation  in  Injuries  from  Foreign  Bodies  in  the 
Eye,"  Philadelphia  Medical  Journal,  February  i,   1902,  pp.  208-212. 

2  "  A  New  Localizer  for  determining  the  Position  of  Foreign  Bodies  in  the  Eye  by  the 
Roentgen  Rays,"  Philadelphia  Medical  Journal,  February  I,  1902,  pp.  213-220. 


720     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

of  the  eye,  and  its  geometrical  shadow  thrown  on  the  photographic  plate  aids  in 
locating  a  foreign  body  in  the  orbit  or  eyeball. 

The  photographic  plate  is  adjusted  on  the  side  of  the  temple  near  the  injured 
eye,  and  the  Crookes'  tube  is  so  placed  that  the  X-rays  fall  as  perpendicularly  as 
possible  upon  it.  If  the  foreign  body  is  within  the  shadow  of  the  localizer,  it  is  in 
front  of  the  equator  of  the  eyeball ;  if  behind  the  shadow  of  the  localizer,  in  the 
posterior  portion  of  the  globe  or  orbit.  A  second  photograph  giving  an  occipito- 
frontal view  identifies  the  quadrant  in  which  the  foreign  body  lies. 

Dr.  Fox  has  varied  this  localizer,  and  has  made  it  of  two  nearly  concentric 
gold  or  silver  circles  connected  by  four  wires.  He  has,  however,  generally 
obtained  better  results  with  the  form  first  described.  His  latest  modification 
is  the  use  of  a  band  of  a  smaller  diameter  than  0.75  millimetre,  and  the  shadow 
cast  by  it  is  so  small  that  the  foreign  body  must  be  very  small  to  be  hidden  by 
the  localizer. 

Dr.  Fox  applies  a  solution  of  cocaine  to  the  eye  before  adjusting  the  localizer, 
in  order  that  it  may  remain  in  place  long  enough  to  take  two  X-ray  photographs 
without  inconveniencing  the  patient. 

Qisophagi/s.  —  George  Hamilton  Gibson'  advocates  the  plan  of  removmg  a 
foreign  body  from  the  oesophagus  while  guiding  the  movement  of  the  coin-catcher 
by  means  of  the  fluorescent  screen.  The  patient  may  be  seated  in  a  chair  with 
the  tube  behind  him,  or  lying  on  a  canvas  couch  with  the  tube  below  him. 
Gibson  has  removed  a  number  of  foreign  bodies  in  this  way,  and  advises  this 
plan  as  least  dangerous  to  the  life  of  the  patient.  He  has  known  of  two  cases 
in  which  coins  that  had  been  some  time  in  the  gullet  were  driven  through  the 
walls  by  the  coin-catcher,  the  patients  having  been  removed  to  the  operating 
room,  after  the  coins  had  been  located,  before  the  attempt  was  made  to  extract 
them. 

Stomach.  —  Mr.  Stephen  Mayou  -  has  devised  a  means  for  witlidrawing  foreign 
bodies  of  iron  or  steel  from  the  stomach  by  the  aid  of  the  X-rays.  He  uses  a  small, 
round  electromagnet,  5  centimetres  long  and  8  millimetres  in  diameter,  the  ends 
and  centre  of  which  are  made  of  soft  iron  and  wound  in  the  ordinary  way,  having 
a  hfting  power  of  a  quarter  of  a  pound  "  when  connected  with  stiff  wires  to  a 
four-volt  battery."  The  magnet  is  inserted  into  an  ordinary  stomach  tube,  the 
end  of  which  is  cut  off,  or  preferably  into  a  celluloid  tube,  which  has  a  perfectly 
smooth  inner  surface,  and  within  which  the  magnet  can  be  drawn  up  and  down 
with  ease  by  pulling  on  the  stiff  connecting  wires.  A  narrow  silver  band  is  placed 
on  the  outer  side  of  the  stomach  end  of  the  tube,  so  that  this  end  may  be  easily 
seen  in  the  stomach  by  means  of  the  X-rays,  the  remainder  of  the  tube  casting 
no  shadow. 

When  a  foreign  body  is  to  be  extracted,  the  patient  lies  on  his  back  with  the 
Crookes'  tube  below  him  and  the  fluorescent  screen  on  his  abdomen.     The  tube, 

^  "  Note  on  the  Removal  of  Foreign  Bodies  from  the  (Esophagus  by  an  Improved  Method  of 
using  the  Roentgen  Rays,"  The  Lancet,  December  13,  1902,  pp.  1623- 1624. 

2  "  A  Method  of  removing  Small  Metallic  Foreign  Bodies  from  the  Stomach  without  Exter- 
nal Operation,"  The  Lancet,  December  6,  1902,  pp.  1 535-1 537. 


APPENDIX  721 

containing  tlie  magnet,  that  should  protrude  6  miUimetres,  is  passed  into  the 
stomach,  preferably  under  an  anaesthetic.  The  X-ray  tube  is  excited  and  the 
magnet  brought  into  contact  with  that  part  of  the  foreign  body  most  suitable  to 
draw  into  the  tube ;  the  current  is  then  allowed  to  flow  through  the  magnet,  and 
the  foreign  body  is  drawn  into  the  tube  by  means  of  the  connecting  wires. 
\\'hen  the  foreign  body  is  in  the  tube,  as  indicated  by  its  position  above  the  silver 
ring,  the  tube,  magnet,  and  foreign  body  are  withdrawn.  Tubes  and  magnets  of 
various  shapes  and  sizes  suited  to  a  given  foreign  body  and  the  oesophagus  of 
the  patient  can  be  used. 

Mr.  Mayou  mentions  one  case  that  Mr.  Burghard  placed  in  his  hands,  in  which 
he  had  used  the  means  described.  The  patient  was  a  boy  a  little  over  two  years 
old,  who  had  swallowed  a  large-sized  hairpin.  This  hairpin  was  located  by 
means  of  the  X-rays,  and  was  found  to  be  to  the  right  of  the  median  line  below 
the  shadow  of  the  liver ;  it  was  in  a  vertical  position,  and  apparently  across  the 
pyloric  orifice.  Seven  weeks  after  admission  to  the  hospital,  the  patient  had 
attacks  of  diarrhoea  and  vomiting.  The  hairpin  meanwhile  had  passed  into  the 
duodenum,  and  was  lying  about  on  a  level  with  the  umbilicus.  The  method 
described  above  was  employed,  and  the  magnet  brought  into  contact  with  the 
blunt  end  of  the  hairpin.  Then  the  tube,  magnet,  and  hairpin  were  withdrawn. 
The  patient  left  the  hospital  the  same  day. 

Diseases  of  the  Bones 

Dystrophy  of  Bones.  —  Henri  Molin  ^  in  a  radiographic  and  clinical  study  of 
bony  dystrophy  characterized  especially,  from  the  clinical  point  of  view,  by  the 
partially  arrested  development  of  the  skeleton,  concludes  that  the  long  bones  of 
the  limbs  and  the  metacarpal  and  phalangeal  bones  of  the  hand  are  most 
frequently  attacked  ;  that  the  long  bones  present  curvatures  similar  to  those  seen 
in  rickets  ;  that  the  articular  malformations  observed,  outward  (genu  varum),  and 
inward  (genu  valgum)  curving  of  the  knee,  etc.,  must  be  considered  as  a  direct 
consequence  of  these  bony  changes ;  that  radiography  alone  has  enabled  the 
practitioner  to  suspect  the  nature  of  this  dystrophy,  which  resembles  rickets,  and 
more  especially  chondroma,  but  is  not  exactly  like  either  of  these  processes. 

Disease  of  Hip  Joint.  —  Victor  Gardette  -  in  an  article  concerning  the  use 
of  radiography  in  disease  of  the  hip  joint  comes  to  the  conclusion  first  that 
radiographs  furnish  sufficiently  accurate  knowledge  of  the  lesions  in  this  disease 
and  permit  the  practitioner  to  distinguish  three  principal  varieties  in  children  :  — 

{a)  Hip-joint  disease  with  diffuse  lesions. 

if))  With  localized  bony  foci. 

(^)  Hip-joint  disease  in  which  deformities  predominate. 

Second,  the  radiographs  are  ordinarily  clear  enough  to  determine  a  doubtful 
diagnosis.  Localized  bony  changes  can  be  recognized,  when  they  exist,  and  the 
seat  of  the  disease,  whether  femoral  or  acetabular,  can  be  determined,  but  its 
nature,  whether  sequestral  or  caseous,  cannot  be  determined. 

^  "  La  Dyschondroplasie,"  These,  Lyon,  1900. 

2  "  Application  de  la  radiographic  a  I'etude  de  la  coxalgie,"  Dec.  These,  Lyon,  1898. 

3A 


72  2   THE  ROENTGEN  RAYS  IN  MEDICINE  AND  SURGERY 

Third,  the  radiographic  examination  is  of  no  assistance  in  the  treatment 
of  the  diffuse  form  of  hip-joint  disease;  but  in  the  locaHzed  variety  it  may  justify 
the  search  for  the  bony  foci  and  its  treatment  by  a  conservative  operation  if 
it  is  accompanied  by  an  abscess  and  is  seated  at  a  certain  distance  from  the 
articulation  ;  in  the  other  cases  waiting  is  preferable,  but  exact  knowledge  con- 
cerning the  lesions  permits  the  surgeon  to  make  resections  earher,  and  thus  to 
obtain  better  functional  results. 

Fourth,  in  cases  where  deformity  is  present,  radiography  enables  the  prac- 
titioner to  learn  the  exact  location  and  extent  of  such  deformities,  and  to  deter- 
mine better  whether  anything  should  be  done,  and  if  so,  the  nature  of  the 
intervention. 

Beck^  describes  a  case  of  osteomyelitis  in  a  woman  twenty  years  of  age,  in 
which  the  symptoms  seemed  to  justify  a  fear  that  a  malignant  growth  was  present. 
The  radiograph  showed,  however,  periostitic  proliferations  and  a  circumscribed 
osteomyelitic  focus  in  the  humerus.  The  focus  was  exposed  by  the  chisel,  and 
the  patient  made  so  speedy  a  recovery  as  to  confirm  the  evidence  given  by  the 
radiograph  of  the  integrity  of  the  remaining  portions  of  the  humerus. 

Sequestrum. —  He  also  describes  another  case  in  which  the  X-rays  were  of 
assistance  in  pointing  out  the  true  cause  of  the  ditificulty.  The  patient  was  a  man 
twenty-three  years  of  age  who  had  crushed  his  left  little  finger.  Extensive  tissue 
necrosis  in  the  muscular  interstices  of  the  forearm  demanded  deep  incisions, 
which  showed  that  the  radius  as  well  as  the  ulna  were  denuded  of  periosteum. 
The  process  was  confined  to  the  forearm,  and  recovery  seemed  rapid,  but  a  small 
fistula  at  the  dorsum  of  the  forearm  did  not  close.  The  probe  did  not  indicate 
the  presence  of  rough  bone,  but  the  X-rays  showed  a  large  splinter  exfoliated 
from  the  inner  portion  of  the  radius,  the  surface  of  which  was  covered  with 
osteophytes.  The  sequestrum  was  found  to  be  covered  by  thick  fibrous  tissue  at 
the  upper  surface,  while  the  inner  and  lower  surfaces  were  exposed.  These  con- 
ditions  showed  why  the  probe  gave  no  information,  as  it  only  came  in  contact 
with  the  fibrous  cover.     Recovery  was  perfect  eleven  days  after  operation. 

Osseous  Cysts.  —  Beck  states  that  osseous  cysts  in  their  early  stage  are  easily 
overlooked  because  the  symptoms  are  at  first  shght  and  may  not  be  appreciated 
until  a  fall  has  produced  a  fracture  of  the  thin  cortex,  therefore  the  information 
given  by  the  X-rays  is  valuable.  The  X-rays  enable  the  practitioner  to  discrimi- 
nate between  osseous  cysts  and  osteosarcoma.  In  the  former  the  line  of  the  cortex 
appears  narrow,  because  it  is  thin,  but  well  marked  and  regular  ;  the  fluid  centre 
of  osseous  cysts  is  indicated  by  a  lighter  shadow  in  the  radiograph. 

^"The  Roentgen  Rays  in  differentiating  between  Osteomyelitis,  Osseous  Cyst,  Osteosar- 
coma, and  Other  Osseous  Lesions,  with  Skiagraphic  Demonst rations, "_/i3«r«a/  American  Medi- 
cal Association,  January  4,  1902,  pp.  28-33. 


APPENDIX  72 -^ 

The  following  list    includes  many  references  to  articles  on  the  therapeutic 
uses  of  the  X-rays  i^ublished  prior  to  January  i,  1903. 

Allen,    Charles  Warrenne.     "Radiotherapy  in  Cancer  and  Skin  Diseases."     New  York 
State  Journal  of  Medicine,  June,  1902,  p.  176. 

"The  Present  Status  of  Radiotherapy  in  Cutaneous  Diseases  and  Cancer."  Medical 
Record,  November  15,  1902,  p.  762. 

Allen,  Seabury  W.    "  X-Ray  Treatment  of  Malignant  Disease."    Boston  Medical  and  Surgical 
Journal,  October  16,  1902,  p.  431. 

Beck,  Cakl.     "The   Pathological  and   Therapeutic  Aspects  of  the   Effects  of  the   Roentgen 
Rays."     Medical  Record,  1902,  LXI,  pp.  83-88. 

"  The  Pathology  of  the  Tissue  Changes  caused  by  the  Roentgen  Rays,  with  Special  Refer- 
ence to  the  Treatment  of  Malignant  Growths."  New  York  :Medical  Journal,  1502,  LXXV, 
pp.  881-885. 

"The  Roentgen  Rays  in  Medicine."  ■  Twentieth  Century  Practice  of  Medicine,  XXI, 
Supplement,  pp.  I-71. 

"  Beitrag  zur  Diagnostik  und  Therapie  der  Struma."  P^ortschritte  a.  d.  Gebiete  d.  Roent- 
genstr.,  1900-1901,  IV,  pp.  122-125. 

Beclere.     "Les  Mesures  Exactes  en  Radiotherapie."     Ann.  d.  Dermat   et  Svphil     190^   4  s 

III,  pp.  60-68.  '         "         "'       ■' 

Behrend,  Gustav.     "  Ueber  die   unter  dem  Einfluss  der  Rontgenstrahlen  entstehende  Haut- 

veranderung."     Berliner  klin.  Wochenschr.,  1898,  23,  pp.  509-511. 
Blacker,  A.  B.     "  Comparison  of  Reactive  Effects  of  P'insen's  and  X-Ray  Treatment."     British 

Medical  Journal,  1901,  II,  p.  850. 
BoNDURANT,  E.  D.    "  Some  of  the  Therapeutic  Uses  of  the  X-Ray."    New  York  Medical  Jour- 
nal, 1902,  LXXVI,  pp.  194-196. 
Bowles,  R.  L.     "  Pathological  and  Therapeutical  Value  of  the  Roentgen  Rays."     The  Lancet, 

1S96,  I,  p.  655. 
Brokaw,  a.  V.  L.    "  X-Rays  as  a  Therapeutic  Agent."     Read  before  the  Alumni  Society  of  the 

Medical  Department   of    Washington   University,  October  9,    1902.     Reprinted  from  St. 

Louis  Courier  of  Medicine,  1902,  XXVII,  pp.  321-336. 
Cross,  J.  G.    "The   Present   Status  of  the  X-Ray  in   Medicine  and   Surgery."    Northwestern 

Lancet,  1901,  XXI,  pp.  205-209. 
DfXEPiNE,  S.     "Therapeutic  Use  of  Roentgen's  Rays."     British  Medical  Journal,  1896,  I,  p.  559. 
DoNATH,  B.     "  Die    Einrichtung   der    Erzeugung  von    Rontgenstrahlen   und   ihr    Gebrauch. " 

Berlin,  1899,  Reuther  u.  Reichhardt. 
Ehrmann.    "  Erfahrungen  tber  die  Therapeutische  Wirkung  der  Elektricitat  und  der  X-Strah- 

len."     Wiener  Med.  Woch.,  1901,  II,  pp.  141 7-1420 ;    1466-1467. 
Evans,  D.  E.,  and  Williams,  T.  V.     "  A  Large  Complicated  Enchondrosarcoma  removed  by 

Simple  Incision  and  X-Ray."     American  Medicine,  December  13,  1902,  p.  925. 
FoRSTER,  A.      "  Einwirkung  der   Roentgen'schen    Strahlen    auf  die  normale   Haut   und   den 

Haarboden."     Deutsche  Med.  W^och.,  1897,  XXIII,  p.  105. 
Fkelnd,  Leopold.     Note  on  "Verwendung  von  Rontgenstrahlen  zur  Behandlung  von  Ilaut- 

krankheiten."     Klin.-therap.  Woch.,  1898,  48,  pp.  1675-1676. 

"Die  Radiotherapie  der  Hautkrankheiten."     Wiener  klin.  Woch.,  1899,  XII,  pp.  966- 

967. 

"  Medical  Use  of  the  X-Rays."     British  Medical  Journal,  1899,  II,  Epitome,  p.  85. 

"Ueber  Radiotherapie."     Wiener  Med.  Presse,  1899,  XL,  pp.  1285-1292. 

"  Verschiedene   Strahlungen   als   Therapeutische  Agens."      Fortschritte  a.   d.   Geb.    d. 

Roentgenstr.,  1901-1902,  V,  p.  77. 

"  Verschiedene  Strahlungen  als  Therapeutische  Faktoren."     Arch.  f.  Dermat.  u.  Syph., 

1902,  LXI,  pp.  437-442. 


724      i'HE    ROENTGEN    RAVS    IN    MEDICINE    AND    SURGERY 

Freund,  L.,  unci  SCHlFi",  E.     "  Weitere  Anwendungsgebiete  der  Radiotherapie."     Fortscliritte 

a.  d.  Geb.  d.  Roentgenstr.,  1899-1900,  III,  pp.  109-110. 
FUCHS,  P.     "  Ueber  den  Einfluss  von  Kathodenstrahlen  auf  die  Haut."     Deutsche  med.  Wocli., 

1896,  35.  P-  569- 
Gardiner,  F.     "An  Unusual  Efl'ect  of  X-Rays  in  a  Case  of  Ringworm  of  the  Scalp."     Scottish 

Med.  and  Surg.  Jour.,  1902,  X,  p.  417. 
Gassmann  und  Schenkel.     "  Fin  Beitrag  zur  Behandlung  der  Hautkrankheiten  mittels  Ront- 

genstrahlen."    Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  Bd.  II,  H.  4,  1S98-1S99,  pp.  131-132. 
GoCHT,   Hermann.     "  Anklage  wegen  '  fahrlassiger  Korperverletzung '  nach  Anwendung  der 

Rontgenstrahlen  (Rontgendermatitis)."     Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  1S98-1899, 

II,  pp.  110-I14. 

"  Therapeutische  Verwendung  der  Rontgenstrahlen."     Fortschritte  a.  d.  Geb.  d.  Roent- 
genstr., 1897,  I,  pp.  14-22. 

"  Therapeutische  Verwendung  der  Rontgenstrahlen."  Therap.  Monatsch.,  1897,  ^^>  P-  ^^4. 
Hahn,  R.     "  Kritische  Bemerkungen  iiber  den  von  Grouven  in  der  Niederrheinischen  Gesell- 

schaft  fiir  Natur  und  Heilkunde  in  Bonn  gehaltenen  Vortrag  iiber  Rontgentherapie  bei 

Hautkrankheiten."     Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  1900-1901,  lY,  pp.  89-90. 
Hall-Edwards,  J.      "On  the  Therapeutic  Effects  of  Light  and  the  X-Rays."      Birmingham 

Med.  Rev.,  1902,  LI,  pp.  334-350. 
Harris,  L.  H.     "  Production  and  L^se  of  the  Roentgen  Rays."     Australasian  Med.  Gazette, 

1 901,  Janiiary  25,  February  20. 

"Therapeutics  of  the  Roentgen  Rays."    Australasian  Med.  Gazette,  September  20,  1902, 

pp.  448-450- 
Hawks,  H.  D.     "  Hair  grows  out  Thicker  after  the  X-Rays  remove  It.      Effect  on  the  Eyes." 

Electrical  Review,  February  10,  1897,  P-  ^7- 
Hazleton,   E.  B.     "X-Rays  in  the  Treatment  of  Phthisis."     The  Lancet,  January  11,  1902, 

p.  121. 
Hendrix,  L.     "  Essais  de  Therapeutique  Chirurgicale  par  les  Radiations  de  Roentgen."     Ann. 

See.  beige  de  Chir.,  1897-189S,  V,  pp.  130-133. 
Heyerdahl,  S.  a.       "  Om   Rontgenstraalerne   og   deres  praktiske   anvendelse   i  medicinen." 

(Sur  les  rayons  de  Roentgen  et  leur  emploi  pratique  en  medecine.)     Norsk.  Mag.  f.  Laege- 

vidensk.,  1898,  4.  R.,  XIII,  pp.  697-721. 
Hopkins,  George  G.     "On  the  Dosage  in  Radiotherapy."     Phila.  Med.  Journal,  September  27, 

1902,  pp.  433-434- 

"  Light  and  Radiance  in  the  Treatment  of  Disease."     Phila.  Med.  Journal,  April  5,  1902, 

pp.  626-627. 
Huber.    "  Notes  on  Some  of  His  Cases  demonstrated  by  X-Ray  Photographs."     Berliner  klin. 

Woch.,  1896,  9,  p.  195. 
Imlach,  F.     "The  X-Rays  as  Curative  Agents."     Scalpel,  1896,  I,  pp.  261-263. 
King,  E.  E.     "  Skin,  Hair,  and  Nail  Lesions  produced   by  the  Action  of  X-Rays."     Canad. 

Pract.,  1896,  XXI,  pp.  789-793. 
King,  W.  H.     "Some  Therapeutical  Experiments  with  the  X-Ray."     Jour.  Electrother.,  1898, 

XVI,  pp.  104-111. 
Kronacher.     "  Heteroplastische  Erfahrungen."     Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  1899- 

1900,  HI,  pp.  59-64. 
KiJ.MMELL,  H.     "Die   Roentgenstrahlen  im  Dienste  d.  practischen  Medecin."     Berliner  klin. 

Woch.,  1901,  38,  pp.  4-7  ;   43-45. 
Lanxashire,   G.   H.     "The  Therapeutic   Employment   of  X-Rays."  British    Medical  Journal, 

1902,  I,  pp.  1 328- 1 330. 
Lecherche,  L.     "  Action  des  rayons  X  sur  la  chaleur  rayonnee  par  la  peau."     Compt.  rend. 

Acad.  d.  Sc,  Paris,  1897,  CXXV,  p.  583. 


APPENDIX 


725 


Ledermann.     "  Ueber  Wirkungen  der  Koentgenstrahlen  auf  die  Haut."    Dermat.  Ztschi.,  1898, 

V,  pp.  492-494- 
Leigh,  Solthcate.     "  Therapeutic  Effect  of  the  Roentgen  Ray."     American  X-Ray  Journal, 

April,  1899,  p.  559. 
Loevvald.     "  Traitement  des  maladies  de  la  peau  par  la  lumiere  concentree  et  les  rayons  X  ; 

methode  de  Finsen."     Mai.  Cut.  et  Syphil.,  1900. 
Lvox,  T.  G.     "  Roentgen's  Rays  as  a  Cure  for  Disease."     The  Lancet,  1896,  I,  pp.  326,  513. 
MacLntyre.     "The  Value  of  Light,  Roentgen  Rays,  etc.,  in  the  Treatment  of  Lupus,  Rodent 

Ulcer,  and  Cancer."     British  Medical  Journal,  1902,  II,  p.  1344. 
Makie    et    Cllzet.      "  Premiers    resultats    electrotherapeutiques    et    radiographiques    obtenus 

a  ITIotel-Dieu  de  Toulouse."     Arch.  Med.  de  Toulouse,  1897,  m>  PP-  403.  437-     1898,  IV, 

pp. 23-26. 
Meek,  E.  R.     "  A  Variety  of  Skin  Lesions  treated  by  the  X-Rays."      Boston  Medical  and  Sur- 
gical Journal,  1902,  CXLVII,  pp.  152-153. 
Morris,  M.    "  Finsen's  Light  and  X-Rays  in  Treatment  of  Skin  Diseases."     (Discussion.)    The 

Lancet,  1901,  II,  pp.  405-407. 
Morton,  William  J.     "  Recent  Advances  in  Electrotherapeutics."     Medical  News,  Decem- 
ber 27,  1902,  pp.  1201-1202. 
NoBL.     "  Rontgentherapie."     Wiener  Med.  Presse,  1900,  XLI,  pp.  301-305. 
OUDIX.     "Considerations  sur  la  Radiotherapie."     Ann.  de  Dermat.  et  Syphil.,  1902,  4  s..  Ill, 

pp.  54-60. 
OuDiX,  Barthelemy  und  Darier.     "  Ueber  Veranderungen   an   der    Haut   und   den    Einge- 

weiden  nach  Durchleuchtung  mit  X-Strahlen."    (Ubersetzt  von  J.  Turkheim.)     Monatsch. 

f.  prakt.  Dermat.,  1897,  ^^^  •  PP-  417-445- 
OuDix  et  BilCLERE.     "Pratique  de  la  Radiotherapie."     Presse  Med.,  1902,  I,  pt.  2,  p.  46. 
Ploxski.     "  A  Case  of  Change  in  the  Skin  produced  by  Roentgen  Rays."     Med.  Press  and 

Circ,  February  22,  1S99,  p.  190. 
PuSEY,  W.  A.     "Cases  of  Sarcoma  and  Hodgkin's  Disease  treated  by  Exposure  to  X-Rays." 

Journal  Am.  'Sled.  Assoc,  January  18,  1902.     "A  Report  of  Cases  treated  with  Roentgen 

Rays."     Journal  Am.  Med.  Assoc,  1902,  XXXVIII,  pp.  911-919. 

"  Roentgen  Rays  in  the  Treatment  of  Skin  Diseases   and   for   the  Removal  of  Hair." 

Chicago  Medical  Recorder,  April,  1900,  pp.  279-290. 

"  Roentgen  Rays  in  the  Treatment  of  Diseases  of  the  .Skin."     Trans.  Am.  Dermat.  Assoc, 

1901,  pp.  184-198.     Journal  Am.  Med.  Assoc,  1901,  XXXVII,  pp.  820-825. 
RiEDER,  H.      "  Therapeutische    Versuche   mit    Rontgenstrahlen    bei   infectiosen    Processen." 

Miinchener  Med.  Woch.,  1899,  XLVI,  pp.  950-954. 
Salvador,  S.     "  Observations  cliniques  et  recherches  de  physique  experimentale  concernant  les 

effets  pathologiques  et  therapeutiques  des  rayons  X  sur  la  peau."     These  de  Lyon,  1899, 

No.  151. 
SCHIFF,  Eduard.     "  Das  Institut   fur   Radiographic  und   Radiotherapie  in  Wien."     Festschr. 

Kaposi,  1900,  pp.  869-876. 

Note  on  "Neue  Erfahrungen  iiber  die  Radiotherapie."     Klin.-therap.  Woch.,  189S,  No. 

47,  pp.  1644-1645. 

"  TJber  die  Einfiihrung  und  Verwendung  der  Rontgenstrahlen  in  der  Dermatotherapie." 

Archiv.  fur  Dermat.  und  Syph.,  1898,  Bd.  42,  pp.  3-14. 

"IJber  die  Therapeutische  Verwerthung  der  X-Strahlen."     Wiener  Med.  Blatter,  1899, 

XXII,  pp.  849-850. 
SCHIFF,  E.,  und  Freuxd,  L.     "  Beitrage  zur  Radiotherapie."     Wiener  Med.  Woch.,  1898,  No.  22, 

pp.  1058-1062  ;  No.  23,  pp.  1118-1122  ;  No.  24,  pp.  1177-1180. 

"  Der    gegenwartige    Stand   der   Radiotherapie."    Wiener    Klin.    Woch.,    1900,  No.  37, 

pp.  827-829. 


-26  THE  ROENTGEN  RAYS  IN  MEDICINE  AND  SURGERY 

"  Etat  actuel  de  la  Radiotherapie."     Zeitschr.  f.  Electrother.  und  arzt.  Klectrotech.,  1900, 
II,  pp.  113-115- 

"Welches  ist  das  wiiksame  Agens  in  der  Radiotherapie?"       Klin.-therap.  Woch.,  1901, 
VIII,  pp.  1-8,  46-50. 
Schmidt,  C.     '"Therapeutisches."      Fortschritte  a.  d.  Geb.  d.   Roentgenstr.,   1899-1900,  III, 

pp.  13-14. 
SCHOLTZ.     "  Ueber   den    Einfluss   d.    Ronlgenstrahlen   a.   d.  Haut    in    gesundem   u.    krankem 

Zustande."     Arch.  f.  Dermat.  u.  Syph.,  Vol.  59,  1902,  pp.  85-104,  241-260,  421-445. 
SCHONBEKC.     "  Traitement  des  maladies  de  la  peau  par  les  rayons  X."     Arch,  d'electr.  med., 

1900,  No.  86. 

Sequeira,  J.  H.     "The  X-Ray  Treatment  in  Diseases  of  the  Skin."     British  Medical  Journal, 

1901,  II,  p.  850. 

Sh.\rpe,  Margaret  M.     "The  X-Ray  Treatment  of  Skin  Diseases."     Arch,  of  the  Roentgen 

Ray,  February,  1900,  pp.  52-60. 
Sjogren  und  Sederholm.      "  Beitrag  zur  therapeutischen  Verwertung  der  Rontgenstrahlen." 

Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  1900-1901,  IV,  pp.  145-170. 
Skinner,  Clarence  E.     "X-Light  in  Therapeutics."     Medical  Record,  December  27,   1902, 

p.  1007. 
SoBOTTA,  E.     "  Rontgen-Diagnose  und  Riintgen-Therapie."     Allg.  Med.-Cent.  Ztg.,  1901.  LXX, 

pp.  777-779- 
Stenbeck.     "  Deux  cas  de  cancroide  gueris  par  les  rayons  Rontgen."     Ann.  d'electrobioL,  1900, 

No.  5. 
Stover,  G.  H.     "The  Therapeutic  Use  of  the  X-Ray."     Trans.  Colorado  State  Medical  Society, 

August,  1902,  pp.  199-205. 
Strater.     "  Welche  Rolle  spielen  die  Rohren  bei  der  therapeutischen  Anwendung  der  Ront- 
genstrahlen."    Deutsche  Med.  Woch.,   1900,  No.  34. 
TowLE,  Harvey  P.     "  A  Review  of  the  Literature  of  the  Therapeutic  Use  of  the  X-Rays." 

Boston  Med.  and  Surg.  Jour.,  1901,  CXLIV,  pp.  343-347. 
Unna,  P.  G.     "Zur   Kenntniss   der  Hautveranderungen   nach   Durchleuchtung   mit    Rontgen- 
strahlen."    Deutsche  Med. -Ztg.,  1898,  XIX,  p.  197. 
Walker,  Norman.     "  X-Ray  Treatment  of  Diseases  of  the  Skin."     British  Medical  Journal, 

1901,  II,  p.  852. 
Walsh,  David.     "Superficial  Action  of  the  Rontgen  Rays."     The  Roentgen  Rays  in  Medical 

Work,  London,  1897,  PP-  117-119- 
Weiss,  M.     "  Resultats  therapeutiques  actuels  des  rayons  X."     Gaz.  hebd.  de  med.  et  de  chir., 

July  31,  1898,  pp.  731-732- 
Wenhardt,  JoHANN.     "  A  gyog\'keserletek  a  Rontgenengarrakal  es  azok  nemely  hatasairal." 

(Therapeutic  Experiments  with  the  Roentgen  Rays  and  some  of  their  effects.)      Ujabb. 

gyogyszer.  es  g\'ogymod.,  Budapest,  1897,  PP-  9-ii- 

"  Die  therapeutischen  Versuche  mit    Roentgenstrahlen    und   iiber   die  Wirkung    dieser 

Strahlen."     Pest.  med. -chir.  Presse,  January  9,  189S,  p.  42. 


ACNE 

Campbell,  R.  R.     "Results  obtained  in  the  Treatment  of  Acne  by  Exposure  to  the  X-Rays." 

Jour.  Am.  Med.  Assoc,  August  9,  1902,  p.  313. 
G.AniER.     "Traitement  de  I'acne  et  de  la  couperose  par  les  rayons  X."     Comptes-rendus  du 

XII  Congres  Internat.  de  Med.,  Moscou,  August,  1S97,  PP-  385-386. 
Pakhitonov.     "  L'acne  et  les  rayons  X."     Comptes-rendus  du  XII  Congres  Internat.  de  Med., 

Moscou,  August,  1897,  PP-  382-385. 


APPENDIX 


ALOPECIA   AREATA 


727 


KlENBuCK.     "  Gesellschaft  der  Arzte  in  Wien."     Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  1900- 

1901,  V,  pp.  134-135- 
KoLLE,  F.  S.      "  Alopecia  Areata  as  a  Result  of  Exposure   to  the  Rontgen   Rays."     Brooklyn 

Med.  Jour.,  1896,  X,  pp.  756-759. 
Marcuse,    W.      "  Dermatitis    und    Alopecie    nach    Durchleuchtungsversuchen    mit    Rontgen- 

strahlen."     Deutsche  Med.  Woch.,  1896,  No.  30,  p.  481. 

"  Nachtrag  zu  dem  Fall  von  Dermatitis  und  Alopecie  nach  Durchleuchtungsversuchen 

mit  Rontgenstrahlen."     Deutsche  Med.  Woch.,  1896,  No.  42,  p.  681. 

BACILLI.     BACTERIA 

Bergome  et  Ferre.  "  Action  des  Rayons  de  Roentgen  sur  la  vitalite  et  la  virulence  des  cul- 
tures du  bacille  de  Koch."  Internat.  Med.  Cong.  XII,  1S97,  Moscow,  1899,  II,  pt.  4,  pp. 
91-93- 

Blaikie,  J.  Brunton.  "Note  on  Effect  of  X-Rays  on  the  Growth  of  the  Tubercle  Bacillus 
and  Diphtheria  Toxin."     Scottish  Med.  and  Surg.  Jour.,  May,  1897. 

BoXuNu,  L.,  e  Gros,  G.  "  Sull'  azione  dei  raggi  Roentgen  sui  microrganismi."  Gior.  med.  d.  r. 
esercito,  1897,  XLV,  pp.  568-584. 

MiNCK,  F.  "Zur  Frage  iiber  den  Einfluss  Roentgen'scher  Strahlen  auf  Baclerien."  Miin- 
chener  Med.  Woch.,  1896,  XLIII,  p.  202. 

Riedkk,  II.  "  Nochmals  die  bakterientodtende  Wirkung  der  Rontgenstrahlen."  Miinchener 
Med.  Woch.,  1902,  XLIX,  pp.  402-406. 

"  Weitere  Mittheilung  iiber  die  Wirkung  der  Rontgenstrahlen  auf  Bacterien,  sowie  auf 
die  menschliche  Haut."     Miinchener  Med.  Woch.,  1898,  No.  25,  pp.  773-774. 

"Wirkung  der  Rontgenstrahlen  auf  Bacterien."     Miinchener  Med.  Woch  .  1898,  No.  4, 
pp.  101-104. 

Sabrazes,  J.,  et  Riviere,  P.  "  Recherches  sur  Taction  biologique  des  rayons  X."  Compt. 
rend.  Acad.  d.  Sc.  Paris,  1897,  CXXIV,  pp.  979-982.  Gaz.  Hebd.  d.  Sc.  Med.  de  Bor- 
deaux, 1897,  XVIII,  p.  232. 

SCHAUDIN";.  "  Influence  des  rayons  de  Roentgen  sur  les  protozoaires."  Arch,  d'electr.  med.. 
No.  80,  1900. 

Vox  Wolfenden  and  Forbes-Ross.  "The  Effects  produced  in  Cultures  of  Microorganisms 
and  of  Tubercle  Bacilli  by  Exposure  to  the  Influence  of  an  X-Ray  Tube."  Arch.  Roentgen 
Ray,  August,  1900,  pp.  4-9. 

Zeit,  F.  R.  "  Effect  of  Direct,  Alternating  Tesla  Currents  and  X-Rays  on  Bacteria."  Jour. 
Am.  Med.  Assoc,  1901,  XXXVII,  pp.  1432-1443. 

CANCER 

Beatson,  G.  T.     Discussion  on  the  Treatment  of  Inoperable  Cancer.     British  Medical  Journal, 

October  25,  1902,  p.  1302. 
Beck,  C.     "  On  a  Case  of  Sarcoma  treated  by  the  Rontgen   Rays."     New  V>irk    Med.  Jour., 

1 901,  LXXIV,  pp.  906-909. 
Bryant,  T.     "  Recurrences  of  Cancer  of  the  Breast."     British  Medical  Journal,  May,  1902. 
COLEV,  W.  B.    "  The  Influence  of  the  Roentgen  Rays  upon  the  Different  Varieties  of  Sarcoma." 

American  Medicine,  1902,  IV,  pp.  251-256.     Medical  News,  September  20,  1902,  pp.  542- 

545- 

"  Treatment  of  Cancer  (including  Sarcoma)."     Twentieth  Century  Practice  of  Medicine, 

XXI,  Supplement,  pp.  759-776. 
Damei,,  J.  W.     "The  X-Ray  Treatment  of  Cancers."     Trans.   Med.  Assoc,  of  Georgia.    1902. 
PP-  370-380. 


728     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

Delavan,   D.  B.     "  The    Results  uf  Treatment  of  Laryngeal  Cancer  by  the  X-Ray."     Trans. 

American  Laryngological  Assoc,  1902,  pp.  188-193. 
Ferguson,  G.  B.     "Unfinished  Case  of  Recurrent  Cancer."     British  Medical  Journal,  Febru- 
ary I,  1902. 
Friend,  S.  H.     "Clinical  Report  of  Cancer  of  the   Breast  under  Treatment  by  the  X-Rays." 

Trans.  Wisconsin  State  Med.  Soc,  1902,  XXXVI,  pp.  115-116. 
GRCBBfe,  E.MIL  H.     "  X-Rays  in  the   Treatment  of  Cancer   and  Other    Malignant   Diseases." 

Medical  Record,  Xovember  I,  1902,  p.  692. 
Hearn,  W.  J.     "The  Action  of  X-Rays  on   Inoperable  Cancer."     Annals  of  Surgery,  1902, 

XXXVI,  pp.  293-297. 
Jones,  Lewis.     "Case  of  Recurrent  Cancer  of  the  Breast."     British  Medical  Journal,  1902,  I, 

p.  516. 
Lyster,  Cecil  R.  C.     "The  X-Rays  in  Cancer."     British  Medical  Journal,  1901,  II,  p.  1663. 
Morton,  William  J.     "The   Probabilities  of  the  Action  of  X-Rays   in   Cancer."     Medical 

Record,  1901,  LX,  p.  943. 

"  Radiotherapy  for  Cancer  and  Other  Diseases."     Medical  Record,  1902,  LXI,  pp.  801- 

805. 
Peters,  E.  A.      "Treatment  of  a  Case   of   Scirrhus  Recurrent  Five  Years  in  a  Patient  aged 

Ninety-three;    Improvement."     British  Medical  Journal,  March  i,  1902,  pp.  508-509. 
Rinehart,  J.  F.      "  Treatment  of  Epithelial   Skin-Cancers  and  Sycosis  Non-parasitica  with 

the  X-Ray."     Phila.  Med.  Jour.,  1902,  IX,  pp.  221-222. 

"The  Use  of  the  Roentgen  Rays  in  Skin  Cancer,  etc.,  with  Report  of  a  Case."    American 

Jour.  Medical  Sciences,  July,  1902,  pp.  114-119. 
Scheppegrelle,  W.     "  Case  of  Cancer  of  Larynx  cured  by  the  X-Rays."     X'ew  York  Med.  Jour., 

December  6,  1902,  pp.  984-9S6. 
Skinner,  Cl.\rence  E.      "  X- Light  in  the  Treatment  of  Cancer."     American  X-Ray  Jour., 

Xovember,  1902,  pp.  1219-1234. 
Stenbeck  and  Boll.\.\N.     "  Traitement  du  cancer  de  la  peau  par  les  rayons  X."    Arch,  d'electr. 

med.,  June  15,  1901.      Revue  de  Therapeutiques,  1901,  p.  639. 
Stiver,   E.     "The  X-Ray  in  Cancer  of  the  L'terus."     Cincinnati   Lancet-Clinic,  August   16, 

1902,  p.  151. 
Taylor,  G.  G.  Stopford.     "  Indications  for  the  X-Ray  Treatment  of  Cancer."     British  Medi- 
cal Journal,  February  8,  1902,  pp.  335-336. 
Turner,  Dawson  F.  D.     "  The  Treatment   of  Cancer  by  Phototherapy."     Edinb.  Med.  Jour., 

December,  1902,  p.  534. 
Williams,  Francis  H.     "  X^ote   on  the   Treatment  of  Epidermoid  Cancer  by  the  Roentgen 

Rays."     Boston  Med.  and  Surg.  Jour.,  January  17,  1901,  p.  66. 

"  A  Further  Note  on  the  Treatment  of  Epidermoid  Cancer."     Boston  Med.  and  Surg. 

Jour.,  April  4,  1901,  p.  329. 

"  Some  Cases   of  Cancer   treated  by  the  X-Rays."     Communications  of  Massachusetts 

Medical  Society,  1901,  pp.  705-710. 

"  Notes  on  the  Treatment  of  Some  Forms  of  Cancer  by  the  X-Rays."     Transactions 

American  Association  of  Physicians,  1901,  pp.  166-171. 

"Treatment  of  Certain  P'orms  of  Cancer  by  the  X-Rays."     Jour.  Am.  Med.  Assoc,  Sep- 
tember 14,  1901,  pp.  68S-691. 

"  The  Use  of  the  X-Ray  in  the  Treatment  of  Some  Forms  of  Cancer."     Medical  Record, 

March  15,  1902,  p.  433. 

CARCINOMA 

Clark,  Andrew.     "  The  Effect  of  the  Roentgen  Rays  in  a  Case  of  Chronic  Carcinoma  of  the 
Breast."     British  Med.  Journal,  1901,  I,  pp.  1398-1399. 


APPENDIX 


729 


P'ekguson,  G.  B.      "  Recurrent  Carcinoma  treated  by  the  Roentgen  Rays."     British  Medical 

Journal,  1902,  I,  pp.  265-266. 
Hopkins,   George   G.      "The    Treatment    of  Carcinomatous    Growths    by    Roentgen    Rays." 

Phila.  Med.  Jour.,  1901,  VIII,  September  7,  pp.  404-406.      Phila.  Med.  Jour.,  1902,  IX, 

pp.  626-627. 
JouNsox,  Wallace,  and  Merrill,  Walter  H.    "  The  X-Rays  in  the  Treatment  of  Carcinoma." 

Phila.  jNIed.  Jour.,  1900,  VI,  pp.  1089-1091. 

"The  X-Ray  Treatment  of  Carcinoma."     American  Medicine,  August  9,  1902,  pp.  217- 

21S. 
Pusey,  W.  a.     "  A  Subsequent   Report  on  a  Case  of  Carcinoma,  discharged  as  Hopeless  and 

reported  as  a  Failure."     Jour.  Am.  Med.  Assoc,  August  30,  1902,  p.  487. 

DERMATITIS.     INJURIES.     BURNS 

Apostoli,  G.  "  Pathogenie  et  traitement  d'une  dermatite  tres  grave  consecutive  a  deux  appli- 
cations de  rayons  X."  Compt.  rend,  du  XII.  Cong.  Internat.  Med.,  1897,  Moscou,  1899, 
IV,  pt.  2,  Sec.  VIII,  pp.  493-495. 

Apostoli  et  Planet.  "  Note  sur  un  cas  tres  grave  de  dermatite  de  la  paroi  abdominale  con- 
secutive a  deux  applications  des  rayons  X ;  pathogenie  et  traitement."  Rev.  d'hyg. 
therap.,  1897,  I^'  PP-  266-278. 

Balzer,  F.,  et  MoNSSEAUX.  "  Accidents  cutanes  causes  par  les  rayons  de  Roentgen."  Ann.  de 
Dermat.  et  Syph.,  1899,  3.  s.,  X,  pp.  41-46. 

Banister,  W.  B.  "The  Rontgen  X-Ray  Traumatism."  Nat.  Med.  Rev.,  Wash.,  1897,  8,  VII, 
pp.  127-129. 

Bar  et  Boulle.  "  Ulcerations  profondes  et  troubles  trophiques  graves  de  la  paroi  abdominale 
produits  par  les  rayons  X  chez  une  femme  enceinte  ;  heureuse  influence  des  rayons  rouges." 
Bulletin  de  la  Societe  d'Obstetrique  de  Paris,  1901,  IV,  pp.  251-266. 

Barthelemv,  OuDiX  et  Darier.  "Accidents  cutanes  et  visceraux  consecutifs  a  I'emploi  des 
rayons   X."       Compt.  rend,  du  XII.  Cong.  Internat.  Med.,  1897,  Moscou,  1899,  IV,  pt.  2, 

VIII,  pp.  459-490- 

Below.     "  Eine  Dermatitis  durch   Rontgenstrahlen."     Munchener  Med.  Woch.,  1898,  XLV, 

p.  263. 
Bernard.     "Dermatite  Radiaire."     Lyon  Medical,  1900,  XCIII,  pp.  442-446. 
Bloom,  J.  N.     "An  X-Ray  Burn,  with   Presentation  of  Subject  and  Photograph."      Louisville 

Jour.  Med.  and  Surg.,  1900,  VII,  pp.  289-292. 
Bosc,  P.     "Note  sur  la  perception  des  rayons  de  Roentgen  par  les  hysteriques."     N.  Montpel. 

Med.,  1896,  V,  p.  330. 
Bronson,  E.  B.     "A  Case  of  Dermatitis  due  to  X-Rays."     Jour.  Cutan.  and  Genito-Urin.  Dis., 

1897,  XV,  pp.  478-480. 
Butler,  T.  L.     "  Some  Remarks  on  X-Ray  '  Burns  '  with  Report  of  Cases  Seen."     Am.  Pract. 

and  News,  Louisville,  1900,  XXIX,  pp.  368-374. 
Cassidy,  P.     "  Report  of  a  Severe  X-Ray  Injury."     Medical  Record,  1900,  LVII,  pp.  180-181. 
Codman,  E.  a.      "  A  Study  of  the  Cases  of  Accidental  X-Ray  Burns  hitherto  Recorded."    Phila. 

Med.  Jour.,  1902,  IX,  pp.  438-442. 
CoUARD,  T.  E.     "  X-Rays  ;   a  Curious  Case  of  Dermatitis  traced  to  Rontgen  Rays."     Codex 

Med.  Phila.,  1895-1896,  II,  pp.  295-297. 
Cyrnos,  J.  M.     "Inconveniences  et   dangers  des  rayons  X."     Jour,  d'hyg.,  Paris,  1897,  >^>^II, 

p.  209. 
Dale,  J.  Y.     "  Skiagraphic  Dermatitis."     Medical  News,  1897,  LXXI.  p.  in. 
Destot.     "  Les  troubles  physiologiques  et  trophiques  dus  aux  rayons  X."     Compt.  rend.  Acad. 

d.  Sc,   Paris,   1897,   CXXIV,  pp.   1114-1116. 

"  Sur  les  causes  de  la  dermatite  radiographique."     La  Radiographic,  10,  VIII,  p.  99. 


730     THE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

DF.rTSCHi.ANDEK.     "  Beitrag  zu  dem  Kapitel  der  Hautverbrennung  durch   Rontgenstrahlen." 

Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  1899-1900,  III,  pp.  182-186. 
Fe\kiek,  Ch.     "Deux  observations  de  brulures  par  la  radiographic."     Cong.  Franc,  de  Chir., 

I'aris,  1899,  XIII,  pp.  611-614. 
Fe\kier,  Ch.,  et  Gross,  G.     "  Deux  observations  de  brfilures  par  la  radiographic."     Arch. 

prov.  de  Chir.,  Paris,  1900,  IX,  pp.  1 61-176. 
GassmanX,  a.     "Zur  Histologic  der  Rontgenulcera."     Fortschritte  a.  d.  Geb.  d.  Roentgenstr., 

1S98-1899,  II,  pp.  199-207. 
Hopkins,  G.  G.     "White  Gangrene."     Phila.  Med.  Jour.,  January  6,  1900.  pp.  55-57. 
Jankai',  L.     "  Die  schadlichen  Xebenwirkungen  der  Rontgenstrahlen  bei  Durchleuchtung  und 

Photographic."     Internal.  Phot.  Monatschr.  f.  Med.,  1898,  V,  pp.  1-7. 
Jones,  H.  H.     "  X-Ray  Burn."     Clin.  Journal,  London,  1897-1898,  XI,  ]i.  415. 
Jones,  P.  M.     "  Rontgen  Ray  Injuries."     Phila.  Med.  Jour.,  1899,  IV,  pp.  787-788. 
JlDD,  L.  D.     "  Rontgen  Ray  Injuries."     Phila.  Med.  Jour.,  1899,  IV,  pp.  587-588. 
Kaposi.     "Demonstration  eines  Falles  von  Rontgenisirungs-Ulceration  unter  folgenden  Bemer- 

kungen."     Wiener  klin.  Woch.,  1899,  XII,  pp.  1113-1114. 
KlENBocK.      "  Hautveranderungen    durch    Roentgenbestrahlung    bei     Mensch    und    Thier." 

Wiener  Med.  Presse,   1901,  XLII,  pp.   874-879,  932-938,  987-989,   1036-1040. 
Leonard,  C.  L.     "Roentgen  Ray  Dermatitis."     American  X-Ray  Journal,  X"ovember,  1898, 

pp.  453-456.     .\rch.  of  the  Roentgen  Ray,  February,  1899,  p.  88. 
LiLlENTHAL,  H.     "  Causc  of  Untoward  Effects  ascribed  to  X-Rays."     Medical  Record,  1S97, 

LI,  p.  287. 
Lyon,  Howard.     "An  X-Ray  Burn."     Albany  Med.  Ann.,  1900,  XXI,  pp.  240-244. 
Mercer,  A.  C.     "  Roentgen  Ray  Burns."     Phila.  Med.  Jour.,  January  6,  1900,  p.  6. 
Metcaxf,  W.  p.     "X-Ray  Burns."     Phila.  Med.  Jour.,  1899,  1\",  p.  iioo. 

Orleman,  D.\isy  M.     "  The  111  Effects  of  the  Roentgen  Rays  as  demonstrated  in  a  Case  here- 
with Reported."     Medical  Record,  July  i,  1899,  p.  8. 
Oi'DiN,  Barthelemy  et  Darier.     "Accidents  cutanes  et  visceraux  consecutifs  a  I'emploi  des 

rayons  X."     France  Med..  1898,  XLV,  pp.  113-118. 
Parker,  W.  E.     "  Unusual  Symptoms  produced  by  the   Roentgen  Rays."     X'ew  Orleans  Med. 

and  Surg.  Jour.,  1896-1897,  XLIX,  pp.  158-160. 
Pitkin,  J.  T.     "Injarious  Eftects  of  the  Roentgen  Rays."    American  X-Ray  Jour.,  September, 

1898,  pp.  386-388. 
Plonski,  I>.     "  Dermatitis  nach  Rontgenstrahlen."     Dermat.  Zeitschr.,  Berl.,  1898,  V,  pp.  36-39. 
Prince,  L.  H.     "A  Case  of  X-Ray  Dermatosis."     Phila.  Med.  Jour.,  1902,  X,  pp.  199-200. 
Pusey,  W.  a.     "X-Ray  Burns."     Phila.  Med.  Jour.,  1900,  V,  p.  187. 
Rollins,  W.  H.     "  X-Light  Kills."     Boston  Med.  and  Surg.  Jour.,  February  14,  1901. 
"  Notes  on  X-Light."     Ibid.  February  23,  1901. 

"  Notes  on  X-Light ;   the  control  guinea  pig."     Ibid.  March  28,  1901. 
"  Vacuum  Tube  Burns."     Ibid.  January  9,  1902. 
RuBEL,  Maurice.     "Death  Due  to  X-Ray."     Jour.  Am.  Med.  Assoc,  1902,  XXXIX,  p.  1321. 
RUSHTON,  W.     "'Sunburn'  by  the  Roentgen  Rays."     The  Lancet,  1896,  II,  p.  49 
Schurmayer.     "  Rontgenverbrennungen   und  das  theoretische   Sachverstandigen-Gutachten." 

Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  1901-1902,  V,  pp.  48-51. 
Scott,  J.  M.     "X-Rays."     American  X-Ray  Jour.,  March,  1898,  p.  223. 
Scott,  N.  S.     "X-Ray  Injuries."     American  X-Ray  Jour.,    1897,  I,  pp.  57-66. 
Sehr\v,\ld,   E.     "Dermatitis  nach  Durchleuchtung  mit   Rontgen-Strahlen."     Deutsche  Med. 

\Voch.,  1896,  Vol.  22,  p.  665. 
Stover,  G.  H.     "A  Protest  against  the  Fear  of  Dermatitis  originating  from   Exposure  to   the 

Roentgen  Rays."     West.  Med.  and  Surg.  Gaz.,  1897-1898,  I,  pp.  270-27?. 


APPENDIX  731 

Thomson,    E.     "Roentgen    Ray  Burns."     American  X-Ray  Jour.,  November,    189S,    p.   451. 

Arch,  of  the  Roentgen  Ray,  February,  1S99,  p.  88. 

"Roentgen  Ray  Dermatitis."     American  X-Ray  Jour.,  January,  1899,  p.  494. 
Wallace,  Agnes  McK.     "Some  Serious  Effects  of  the  X-Rav."     Kansas  Med.  Jour.,  1897, 

IX,  p.  88. 
Walsh,  David.     "Deep  Tissue  Traumatism  from  Roentgen  Ray  Exposure."     British   Med. 

Jour.,  1897,  11'  P-  272. 

"  Focus-tube  Dermatitis."     Arch,  of  the  Roentgen  Ray,  February,  1899,  pp.  69-73. 
White,  J.  C.     "Dermatitis  caused  by  X-Rays."     Boston  Med.  and  Surg.  Jour.,  1896,  CXXXV, 

P-  583- 
WiESNER.     "  Beitrag  zur  Kenntniss  der  Rontgendermatitis."     Miinchener  Med.  Woch.,  1902, 

XLIX,  pp.  1047-1049. 
Wilbert,  M.  I.      "  On  a  Source  of  Danger  to   Rontgen   Ray  Experimenters."      Phila.  Med. 

Jour.,  May  6,  1S99,  p.  1014. 

ECZEMA 

Hahn,  R.     "  Die  Rontgentherapie  bei  Ekzem,  Rosacea,  Acne  Vulgaris  und  Prurigo."     Fort- 

schritte  a.  d.  Geb.  d.  Roentgenstr.,  1901-1902,  V,  pp.  39-41. 

"  Durch    Rontgenstrahlen    geheiltes    chronisches    Ekzem."     Fortschritte    a.  d.  Geb.  d. 

Roentgenstr.,  1898-1899,  II,  pp.  16-18. 
Holland,  C.  T.    "  Eczema  treated  by  X-Rays."    British  Medical  Journal,  April  29, 1899,  p.  1024. 

EPITHELIOMA 

Allen,  C.  W.    "  The  X^ature  of   Cutaneous  Epithelioma,  with  Remarks  on  Treatment  by  the 

X-Rays."     Medical  Record,  1902,  LXI,  pp.  125-130. 
Lieberthal,  D.     "  A  Case  of  Epithelioma  developed  on  the  Basis  of  a  Healed  Lupus  \'ulgaris 

treated  by  X-Rays."     Jour.  Am.  Med.  Assoc,  1901,  XXXVI,  pp.  1464-1466. 
McCaw,  James  Francis.     "  Primary  Epithelioma  of  the  Uvula  and  Soft  Palate  and  Treatment 

with  the  Roentgen   Rays,  Report   of  a  Case."     New  York   Med.  Jour.,  August  9,    1902, 

pp.  225-227. 
Sweet,  William  M.     "The  Treatment  of  Epithelioma  of  the  Eyelids  by  the  X-Rays."     Ameri- 
can Medicine,  December  13,  1902,  p.  935. 
Taylor,  G.  G.  Stopford.      "Case  of  Epithelioma  complicating  Lupus  Erythematosus  treated 

by  Scraping  and  healed  by  the  X-Rays."     British  Medical  Journal,  May  3,  1902,  pp.  loSo- 

1082. 
Trowbridge,  E.  H.     "Report  of  Epithelioma  of  Face  cured  by  X-Rays."     Bostt)n  Med.  and 

Surg.  Jour.,  December  25,  1902,  pp.  701-702. 
Varney,  H.  R.     "Roentgen  Rays  in   Epithelioma."     Jour.  Am.  Med.  Assoc,  April  26,  1902, 

p.  1 100. 
Wharton.     "  Epithelioma  of  the  Orbit,  Treatment  by  the  X-Rays."     Annals  of  Surgery,  1902, 

XXXVI,  p.  452. 

HYPERTRICHOSIS 

Havas,  Adolf.     "  Enthaarung   mittelst    RGntgenstrahlen."     Ungar.    Med.    Presse,   Budapest, 
1899,  IV,  p.  35. 

"Epilation  mittelst   Rontgenstrahlen."     Pest.   Med.-Chir.    Presse,   December    11,    1898, 

p.  II 89. 
JUTASSY,  Josef.     "Die  Behandlung  der   Hypertrichosis  mit    Rontgenstrahlen."     Fortschritte 

a.  d.  Geb.  d.  Roentgenstr.,  1898-1899.  II.  pp.  194-197- 
Kaposi.     "Zur  Wirkung  der    Rontgenstrahlen  bei    der  Epilation."      Allg.   Wien.   Med.   Zeit., 

1899,  XLIV,  pp.  383-384. 


732 


THE  ROENTGEN  RAYS  IN  MEDICINE  AND  SURGERY 


ScHiiF.     "Die  Rontgentherapie  bei  Haaicrkrankungen."     Fortschritte  a.  d.  (Jeb.  d.  Roentgen- 

str.,  1901-1902,  V,  pp.  41-43. 
Wooii,  X.     "  Depilation  by  Roentgen  Rays."     The  Lancet,  1900.  I,  pp.  231-232. 

"Treatment  of  Hypertrichosis  by  the  RtJntgen  Rays."     lioston  Med.  and  Surg.  Jour., 
1 90 1,  CXLV,  pp.  301-302. 

KERATOSIS 

Johnston,  J.  C.     "  Precancerous  Keratosis  probably  due  to  X-Rays."     Phila.  Med.  Jour.,  Feb- 
ruary I,  1902,  pp.  220-221. 

LUPUS 

Alders-Schonberg.     "  Beitrag  zur  therapeutischen  Verwendung  der  Rontgenstrahlen  in  der 

Behandlung  des  Lupus."     Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  1897-1898,  I,  pp.  72-75. 
"Uber    die  Behandlung  des  Lupus  und  des  chronischen  Ekzems  niit  Rontgenstrahlen." 

Fortschritte  a.  d.  Geb.  d.  Roentgenstr.,  1898-1899,  II,  pp.  20-29. 
Greenleaf,  C.  a.     "  The  Therapeutic  Value  of  the  X-Ray  in  Lupus  Vulgaris."  Buffalo  Med. 

Jour.,  October,  1901,  p.  189. 

"Four  Cases  of  Lupus  Vulgaris."     Jour.  Am.  Med.  Assoc,  1901,  XXXVII,  p.  1143. 
Groiven,   C.      "  Die    Rontgentherapie   bei   Lupus  und   Scrophuloderm."      Fortschritte   a.  d. 

Geb.  d.  Roentgenstr.,  1901-1902,  V,  pp.  35-37. 

"  Histologische  Veranderungen  des  luposen  Gewebes  nach  Rontgenbehandlung."     Fort- 
schritte a.  d.  Geb.  d.  Roentgenstr.,  1901-1902,  V,  pp.  186-188. 

"  Traitement  du  Lupus  et  du  Sycosis  par  les  rayons  de  Roentgen."     Rev.  de  Therap.  Med. 

Chin,  Paris,  1901,  LXVIII,  pp.  314-315. 

''Therapeutische  Verwendung  der  Rontgenstrahlen."      Deutsche   Med.  Woch.,  1900, 

XXVI,  Ver.-Beil.,  pp.  197-198. 
Hahn  und  Albers-Schonberg.     "  Die  Therapie  des  Lupus  und  der  Hautkrankheiten  mittels 

Rontgenstrahlen."     Miinchener  Med.  Woch.,  1900,  No.  10. 
HiMMEL,  J.     "  Die  giinstige  AVirkung  der  Rontgenstrahlen  auf  den  Lupus  und  deren  X^eben- 

wirkung  auf  die  Haut  und  ihre  Anhangsgebilde."     Arch.  Derniat.  u.  Syph.,  W.  u.  L.,  1899, 

L,  pp.  323-338. 
Holland,  C.  T.     "  Treatment  of  Lupus  by  Roentgen  Rays."     Arch,  of  the  Roentgen  Ray,  May, 

1899,  pp.  1 1 2-1 14.     Phila.  Med.  Jour.,  January  6,  1900,  p.  76. 

"  The  Treatment  of  Lupus  by  X-Rays."   Liverpool  Med.-Chir.  Jour.,  1901,  XXI,  pp.  87-92. 
Jamieson,  W.  a.     "  X-Ray  Treatment  of  Diseases  of  the  Skin."    British  Medical  Journal,  1901, 

II,  p.  851. 
Jones,  P.  M.     "Treatment  of  Lupus  by  X-Rays."    Phila.  Med.  Jour.,  January  6,  1900,  pp.  63-64, 
JUTASSY.     "  Mittelst  Rontgenstrahlen  behandelte  Falle  von  Lupus  Vulgaris,  Lupus  Erythema- 

todes,   Ekzema   Chronicum,  Hypertrichosis  und    Naevus  Vasculosus."      Pest.    Med.-Chir. 

Presse,  1900,  XXXVI,  pp.  73-78. 
KlENBi)CK,  Robert.     "  Ueber  die  Eimvirkung  des  Rontgen-Lichtes  auf  die   Haut."     Wiener 

klin.  Woch.,  1900,  XIII,  pp.  1153-1166. 
Kn'oX,  J.  T.     "Treatment  of  Lupus  Vulgaris  with  X-Rays."  Jour.  Am.  Med.  Assoc,  1900,  XXXV, 

pp.  1210-1213. 
Kl'MMELL.    "Die  Rontgenstrahlen  im  Dienste  der  praktischen  Medicin."     Berliner  klin.  Woch., 

1901,  38,  pp.  4-7,  43-45- 

Morris,  Malcolm.     "  A  Comparison  of  Finsen's  Light  and  X-Ray  Treatment."     British  Medi- 
cal Journal,  May  31,  1902,  p.  1325. 
Fernet,  G.     "  A  X^'ote  on  the  History  of  X-Rayed  Lupus  Vulgaris."     British  Medical  Journal, 

1902,  II,  p.  1319. 

PUSEY,  W.   A.      "  Lupus  healed    with    Rontgen    Rays."      Report   of   case.     Jour.   Am.   Med. 
Assoc,  December  8,  1900,  pp.  1476-1478. 


APPENDIX  733 

Riis,  G.     "  Et  Tilfaelde  af  Lupus  nasi,  behandlet  med   Rdntgenstraaler."     Hosp.-Tid.,  Koen., 

1900,  4  R.,  VIII,  pp.  2-5. 

Rodman,  G.  H.     "  Severe  and  Long-standing  Case  of  Lupus  treated  l)y  X-Rays."     The  Lancet, 

1901,  II,  pp.  1330-1332. 

RuDls-JiciNSKV,  J.    "  Lupus  treated  by  X-Rays."    American  X-Ray  Jour.,  October,  1898,  p.  423. 
Sjogren.     "  Die  Rontgentherapie  bei  Lupus  Erytheniatodes,  Cancroid  and   Ulcus   Rodens."' 

Fortschritte  a.  d.  Geb.  d.  Roentgentstr.,  1901-1902,  V,  pp.  37-39. 
Smith,  A.  E.     "  Lupus  Vulgaris."     Medical  Record,  1901,  LIX,  p.  247. 
Startin,  James.  "  On  X-Rays  in  the  Treatment  of  Lupus  and  Rodent  Ulcer."  The  Lancet,  1901, 

II,  p.  144. 
Swales,  Edward.     "Two  Cases  of  Lupus  Vulgaris  successfully  treated  with  L'rea  Pura  and 

the  X-Rays."     The  Lancet,  March  8,  1902,  pp.  658-659. 
Thurnwald.     "  Vorstellung  eines  mit  Rontgen-Strahlen  behandelten  Falles  von  ausgebreitetem 

Lupus  im  Gesicht."     Wiener  klin.  Woch.,  1899,  XII,  pp.  1163-1164. 
Varnev,  H.  R.     "Treatment  of  Lupus."     Medical  News,  1901,  LXXVIII,  pp.  257-259. 
Walker,  Norman.     "  A  Suggestion  for  the  Treatment  of  Lupus."     Scottish  Med.  and  Surg. 

Jour.,  1902,  X,  p.  416. 

"The  X-Ray  Treatment  of  Diseases  of  the  Skin."     British  Medical  Journal,  1901,  II, 

p.  852. 

"Three  Cases  of  Lupus  treated  by  the  X-Rays."     Trans.  Med.-Chir.  Soc.  Edinb,,  1901- 

1902,  XXI,  p.  4. 

Woods,  R.  F.     "A  Case  of  Lupus  Erythematosus  cured  by  the  X-Ray."     American  Jour.  Med. 
Sciences,  1901,  CXXII,  pp.  834-836. 

N.EVUS   PIGMENTOSUS 

Fret:nd,  L.     "  Ein  mit  Rontgen-Strahlen  behandelter  Fall  von  Naevus  Pigmentosus  piliferus." 

Wiener  Med.  Woch.,  1897,  XLVII,  pp.  428-434. 
JuTASSY,  Josef.     "  Radiotherapie  eines  Naevus  Flammeus."     Fortschritte  a.  d.  Geb.  d.  Roent- 

genstr.,  1898-1899,  II,  pp.  213-216. 

NEW   GROWTHS 

Cetre,  a.     "  Les  rayons  Roentgen  appliques  a  I'etude  des  affections  medico-chirurgicales  et  en 

particulier  h.  celle  des  tumeurs."     These.  Lyon,  1898,  No.  5. 
Cleaves,  Margaret  A.     "The   Rontgen   Ray  and  Ultra-Violet   Light  in  the  Treatment   of 

Malignant  Diseases  of  the  Uterus,  with  Report  of  an  Inoperable  Case."     Medical  Record, 

December   13,  1902,  p.  921. 
Heeve,  W.  L.     "Chronic  Ulceration  of  the  Leg  treated  by  X-Rays  and  'Brush  Discharge.'" 

American  Medicine,  1902,  IV,  pp.  608-609. 
INIORTON,  W.  J.     "  The  Treatment  of  Malignant  Growths  by  the  X-Ray,  with  a  Provisional  Re- 
port on  Cases  under  Treatment."     Medical  Record,  1902,  LXI,  pp.  361-365. 
RuDis-JiClNSKY,  J.     "The  X-Rays  in  the  Treatment  of  Malignant  Growths."     New  York   Med. 

Jour.,  1902,  LXXVI,  pp.  370-372. 
Taylor,  G.  G.  Stopford.    "  Therapeutic  Effects  of  the  X-Rays  upon  Diseased  Tissue."     British 

Medical  Journal,  1901,  II,  pp.  852-853. 

RODENT   ULCERS 

Caird,  F.  M.     "Rodent  Ulcer  treated  by  the   X-Rays."      Trans.  Med.-Chir.  Soc.  Edinb.,  1901- 

1902,  XXI,  p.  97. 
JAMIESON,  Allan.     "The  X-Rays  in  Rodent  Ulcer."     Trans.  Med.-Chir.  Soc.  Edinb.,   1901- 

1902,  XXI,  p.  56. 


734      'i'HE    ROENTGEN    RAYS    IN    MEDICINE   AND    SURGERY 

Levack,  J.  R.    "Case  of  Rodent  Ulcer  treated  by  the  X-Rays."    Scottish  Med.  and  Surg.  Jour., 

1902,  X,  p.  156. 
Morgan,  David.    "  X-Ray  and  Light  Treatment  of  Lupus  and  Rodent  Ulcer."     British  Medical 

Journal,  1902,  I,  p.  516. 
Morris,  Malcolm,  and  Dore,  S.  Ernest.     "  Further  Remarks  on  Finsen's  Light  and  X-Ray 

Treatment   in   Lupus  and    Rodent    Ulcer."     British   Medical  Journal,   May  31,   1902,  pp. 

1 324-1328. 
PUGH,  J.  W.     "  Four  Cases  of  Rodent  Ulcer  treated  by  X-Rays."     British   Medical  Journal, 

1902,  I,  pp.  882-884. 
Sequeira,  James  H.     "A  Preliminary  Communication  on  the  Treatment  of  Rodent  Ulcer  by 

the  X-Rays."     British  ISIedical  Journal,  1901,  I,  pp.  332-334. 

"Treatment  of  Rodent  Ulcer  of  the  Face."     The  Lancet,  1901,  I,  p.  327. 
Stenbeck.     "  Rodent  Ulcers  healed  by  X-Rays."     British  Medical  Journal,  1901,  I,  Epitome. 

p.  36. 

"Treatment  of  Rodent  Ulcer   by  X-Rays."     Hygeia,  Stockholm,   1900,  p.   18.    Abstr. 

British  Medical  Journal,  190a,  II,  Epitome,  p.  12. 
Taylor,  G.  G.  Stopford.     "  A  Case  of  Rodent  Ulcer  of  the  Nose  and  Eyelids  treated  with 

the  X-Rays."     The  Lancet,  1902,  I,  p.  1395. 

SYCOSIS 

Freind,  L.     "  Traitement  du  Sycosis  et  du  Favus  par  les  rayons  X."     Gaz.  Hebd.  de  Med.  et 

de  Chir.,  June  15,  1899,  p.  575. 
ScHiFF,    E.     "  Behandlung    von   Sycosis    und    Ekzem    mit    Rontgenstrahlen."      Klin.-therap. 

Woch.,  June  25,  1899,  p.  851. 
SocoLOFF.     "  X-Rays  in  Treatment  of  Herpes-tonsurans  and  Favus."      Bolnitschnaia  Gazeta 

Botkina,  January  23,  1902,  Phila.  Med.  Jour.,  April  19,  1902. 


INDEX 


Abbe,  Dr.,  use  of  X-rays  by,  for  recognition  of 

calculi,  622,  626. 
Abbot,  Dr.,  on  use  of  X-rays  in  military  surgery, 

553- 
Abdomen,  cases  of  cancer  and  of  carcinoma  of, 
at  Boston  City  Hospital,  442. 
displacement  of  heart  by  distended,  286. 
malignant  disease  of,  346-347. 
new  growths  in,  375-378. 
X-rays  in  studying  diseases  of,  358. 
Abdominal  muscles  an  assistance  in  expiration 

in  emphysema,  197. 
Abscess,  alveolar,  612. 

of  liver,  353.  . 

of  lung,  351-352. 
radiographs  of,  573,  574. 
subdiaphragmatic,  653-654. 
Absorption,  law  of,  of  X-rays,  2. 
Acne,  418,  453,  670-672,  714. 
Acromegalia,  556,  578. 
Action,  mode  of,  of  X-rays,  393. 
Adenitis,  treatment  of,  by  X-rays,  715. 
Adhesions,   displacement   of  heart   by,  290-291, 

293-294.     See  Pleuritic  adhesions. 
Air,  absoiptive  power  of,  4. 

injection  of,  into  intestines,  378. 
introduction  of,  into  organs,  358. 
withdrawing,  in  pneumothorax,  237-238. 
Air  passages,  effects  of  obstruction  of,  200,  201. 
obstruction  of,  due  to  enlarged  glands,  349. 
Air  resistance,  character  of  vacuum  tube  should 

be  defined  by  its,  46. 
Albarran,  Dr.,  recognition  of  calculi  by  X-rays, 

626-627. 
Albers-Schonberg,  concerning  therapeutic  uses  of 
X-rays,   392,   393,   396,    397-398,  399,  402, 
406,  408-409,  411-412,  418. 
report  of,  on  pictures  of  syphilitic  diseases  of 
joints,  597. 
Alcohol,  intemperate  use  of,  a  cause  of  enlarged 
heart,  271. 
skin-tracings  removed  by,  79. 
Alcoholics,   effect   of,   on   appearance  of  lungs, 

307-308. 
Alimentary  canal,  difficulties  of  X-ray  examina- 
tions of,  357. 


Allen,  Dr.  Seabury  W.,  716. 

report  by,  on  X-rays  as  an  analgesic,  663-664. 
Alopecia,  Jutassy's  production  of  a  lasting,  416. 

areata,  treatment  of,  by  X-rays,  673. 
Alsberg,  Dr.,  recognition  of  calculus  by  X-rays, 

625. 
Aluminum,  radiograph  of,  472. 
Aluminum  screen,  47,  53-54,  655. 
Ana-mia,  displacement  of  heart  in,  297. 

examination  of,  by  X-rays,  388. 

pernicious,  389. 

symptom  of  tuberculosis,  117,  120,  162. 
Analgesic,  X-rays  as  an,  445,  663-664. 
Anatomy,  use  of  X-rays  in,  454. 
Aneurisms,  310-331. 

aortic,  operations  unadvisable  when  present, 

331- 
appearances  seen  on  screen  in,  310. 
changes  in  outline  of  heart  due  to,  262. 
difference  of  X-ray  and  percussion  determina- 
tions of  left  heart  border  in  cases  of,  276, 
278. 
effect  of  pressure  of,  on  bronchus,  200,  349. 
enlarged  heart  caused  by,  271. 
illustration  of  difficulty  of  correct  diagnosis  of 

thoracic,  328-329. 
obstruction  of  bronchus  due  to,  349. 
subclavian,  317. 

thoracic,  new  growth  may  simulate,  332. 
Angle  at  which  light  should  pass  through  patient's 

body,  643-645. 
Animals  inoculated  with  bacteria,  effect  of  X-rays 

on,  452. 
Ankle,  cases  of  fractures  of,  at  Boston  City  Hos- 
pital, 456. 
photographing  fractures  of,  501-505. 
time  of  exposure  for  photographing,  640. 
tuberculosis  of,  radiograph  of,  590. 
Ankylosis,  X-rays  of  use  in  examining,  598. 
Anode,  of  vacuum  tubes,  34. 
and  target  united,  35-36. 
Antrum,  cases  of  cancer  of,  at  Boston  City  Hos- 
pital, 442. 
Anus,  case  of  cancer  of,  at  Boston  City  Hospital, 

442. 
Aorta,  aneurism  of,  310,  312-313,  322-324. 
appearance  of,  on  screen,  100. 


735 


1Z^ 


INDEX 


Aorta  (continued)  — 

dilatation  of,  in  aortic  insufficiency,  300. 

dilatation  of,  recognized   by  X-ray  examina- 
tion, 320. 
Aortic  arch  tumor  in  region  of,  329. 
Aortic  insufficiency,  excursion  of  heart  in,  299. 
Apex  beat  of  heart,  252-253. 
Apparatus,  X-ray,  8-58,  636-640. 

for  examining  children,  385. 

in  India,  553. 

for  locating  foreign  bodies,  533-538. 

for  photographing  teeth,  603-606. 

precautions  concerning,  in  therapeutic  uses  of 
X-rays,  446-447,  642-643,  655. 

size  of,  in  surgery,  455. 

in  therapeutic  uses  of  X-rays,   393-394,  401, 
642,  654-655. 

for  treating  cancer,  421-423,  654-655. 
Appendicitis  confounded  with  pneumonia,  192. 
Arc  light,   Finsen's  experiments   with,  and  bac- 
teria, 452. 

in  treatment  of  lupus,  407. 

in  treatment  of  rodent  ulcer,  444. 
Arm,  time  of  exposure  for  photographing,  640. 
Army,  use  of  X-rays  in  the,  553-555. 
Arteries,  X-ray  photographs  of,  386-387. 
Arterio-sclerosis,  317. 

as  cause  of  enlarged  heart,  271. 

inferred  from  enlarged  heart,  283. 
Artery,  pulmonary,  appearance  of,  on  fluorescent 

screen,  100. 
Arthritis,  of  joints,  X-ray  examinations  of  service 
in,  556. 

of  iinger-joints,  radiograph  of,  597. 
Articular  rheumatism,  445,  446. 
Ascites,  375. 

Ascitic  fluid  and  water,  experiment  with,  6. 
Association  of  an   acute   and    chronic  process, 

354- 
Astragalus,  case  of  removal  of,  562. 
Atelectasis    may    be    observed    on    fluorescent 

screen,  353. 
Atomic  weight  of  elements  of  human  body,  2-3. 
Atrophies,  use  of  Jv-rays  in,  672-673. 
Atrophy  of  bone  and  joint  structures,  X-ray  ex- 
aminations of  service  in,  556. 
Auricle,   right,   appearance    of,    on   screen,    100, 
252. 
enlarged,  in  emphysema,  193. 
Auscultation,  examination   by,  in   carcinoma  of 
liver,  376-377. 
in  examining  chest,  109. 
in  examining  heart  and  lungs,  162. 
for  murmurs  of  heart,  301. 
pneumonia  in  early  stages  may  give  no  signs 

by,  183. 
in  cases  of  tumors  in  chest,  339-340. 
more  definite  signs  by  X-rays  than  by,  149. 
X-ray  examinations  should  be  taught  in  con- 
nection with,  355. 


Autopsy,  confirmation  of  X-ray  determinations 
by,  in  cases  of — 

aneurism,  326-328. 
broncho-pneumonia,  192. 
calculi,  622. 
new  growths,  338-339. 
pleurisy,  216-217. 
tumor  of  head,  340,  646. 
A.  W.  L.  universal  coil,  28-31,  63,  640. 

in  photographing  teeth,  603. 
Axilla,  cases  of  cancer  and  of  carcinoma  of,  at 

Boston  City  Hospital,  442. 
Axis  of  heart,  inclination  of,  247-248,  286,  295,  297. 

B 

Back,  case  of  healing  of  ulcerations  on,  after  rays 
had  traversed  body,  419-420. 

Bacteria,  effect  of  X-rays  on,  448-453. 

Bacterium  coli.  X-ray  experiments  with,  450. 

Bagge,  Dr.  Ivar,  case  of  tuberculosis  in  a  wound 
reported  by,  419-420. 

Baldwin,  J.  F.,  localization  of  button  in  oesopha- 
gus by,  540. 

Balthazard,  Dr.,  observation  of  digestive  process 

by,  372-373- 
Bandages,  radiographs  of,  472. 
Bar,  Dr.,  treatment  of  X-ray  burn  by,  661-662. 
Barker,  G.  F.,  i,  2. 

Barthelemy,  on  mode  of  action  of  X-rays  in  treat- 
ment of  lupus,  393. 
on  use  of  X-rays  in  — 

acromegalia,  578. 
Pott's  disease  in  children,  596. 
tubercular  osteitis,  594. 
tuberculosis  of  bones,  592. 
Bassuel  on  heart  in  systole,  254-255. 
Battersby,   Major,  on  use  of  X-rays  in  military 

surgerv,  554. 
Beard,  removal  of,  in  lymphomata  colli,  417. 

sycosis  of  the,  415. 
Beatson,  Dr.,  report  of  case  of  "  stave  of  thumb" 

fracture  by,  492. 
Beck,  description  by,  of  case  of  osteomyelitis,  722. 
experiments  of,  with  color-producing  bacteria 

and  X-rays,  449. 
use  of  radiograph  in  spina  bifida  by,  464. 
use  of  radiograph  to  detect  gall  stones  by,  630. 
Beclfere,  Dr.,  356. 

Becquerel  rays  and  X-rays,  theory  concerning,  i. 
Beevor,  Surgeon  Major,  on  use  of  X-rays  in  mili- 
tary surgery,  553. 
Benedikt,  Dr.,  356. 

on  value  of  X-rays  in  diagnosis  of  diseases  of 
vertebras,  587. 
Bergonie,  Dr.,  cases  of  acute  phthisis  reported 

by,  418. 
Bertin-Sans,  Dr.,  on  study  of  articular  movement 

by  X-rays,  389. 
Berton,  Dr.,  experiments  of,  with  diphtheria  bacilli 
and  X-rays,  449. 


INDEX 


/o/ 


Bevan,  Dr.  Arthur  D.,  recognition  of  calculus  by 

X-rays,  623. 
Bicycle  used  to  charge  storage  battery,  554. 
Birth-mark,  therapeutic  use  of  X-rays  for  remov- 
ing. 453- 
Bismuth,  for  recognizing  diverticulum,  357. 
injected  into  sinus  in  empyema,  241. 
introduction  of,  into  hollow  organs,  358. 
for  observing  intesiines,  378,  651. 
for  recognizing  sinus,  458. 
for  observing  stomach,  359,  362,  366,  369-370, 
373- 
Bladder,  calculi  in,  615. 

cases  of  cancer  and  of  carcinoma  of,  at  Boston 

City  Hospital,  442. 
method  of  examination  for,  621. 
Blaikie,  J.  Brunton,  experiments  of,  with  bacteria 

and  X-rays,  450. 
Blanks  for  X-ray  records,  79-80. 
Blastomycosis,  cutaneous,  treatment  of,  by  X-rays, 

674. 
Blondes,  skin  of,  reacts  most  quickly  to  X-rays, 

416. 
Blood,  specific  gravity  of,  and  water,  experiment 

with,  6-7. 
Blood   vessels,   normal.    X-ray   photographs   of, 

386-387. 
Boas,  Dr.,  fluorescent  screen  used  by,  to  observe 

digestive  tract,  373. 
Body,  constituents  of  the,  3,  5. 

locating   foreign  substances   in,   81-86.      See 

Foreign  bodies, 
photographing  different  parts  of,  88-96,  640. 
Bondurant,  Dr.  E.  D.,  on  use  of  X-rays  in  neu- 
ralgia, 663. 
Bone,  comminution  by  bullets,  shown  by  X-rays, 

554-555- 
comparison  of  well  and  affected,  457. 
decalcified,  radiograph  of,  616. 
diseases  of,  556-587,  721-722. 
disturbance  of  development  of,  in  cretinism, 

461. 
new  growths  in,  332. 
opacity  of,  to  X-rays,  2. 
use  of  X-rays  in  diseases  of,  454. 
Bones,  of  forearm,  radiograph  of  dislocation  of 

both,  527. 
of  leg,  radiographs  of  fractures  of,  505,  506, 

509,  5x6-519. 
long  exposure  for  details  of,  96. 
metacarpal,  fracture  of,  491-492,  494. 
metatarsal,  photographing,  522. 
regeneration  of  after  operation,  562. 
tuberculosis  of,  575. 
Borden,  Captain,  on  use  of  X-rays  in  military  sur- 
gery, 554- 
Borders  of  heart,  method  of  determining,  with 

X-rays,  247. 
Bordier,  Dr.,  on    changes  produced    in  skin  by 

exposure  to  excited  vacuum  tube,  447. 


Boston  City   Hospital,   cases  of   cancers  and  of 
carcinomas  at,  441-442. 
cases  of  fractures  treated  at,  455,  456. 
Bouchacourt,  Dr.,  on   treatment   of  X-ray  burn 
662. 
on  use  of  X-ray  photograph  in  study  of  pelvis, 
378-379- 
Bouchard,  Dr.,  356. 

Boulle,  Dr.,  treatment  of  X-ray  burn  by,  661-662. 
Bowed  leg,  fracture  mistaken  for,  522. 
Bowels   should   be   empty  in  e.xamining   organs 

below  diaphragm,  359-360. 
Box  for  vacuum  tube,  50-55,  400-401,  446,  655. 
Braatz,  Dr.,  recognition  of  calculus  by  X-rays, 

627. 
Brain,  tumors  in,  detection  of,   by  X-rays,   340, 

645-647. 
Break,  Spottiswoode's  electrolytic,  20. 
Breast,  cancers  of  the,  420,  677,  702-710. 

carcinoma  of    treatment  of,  by  X-rays,  421, 

702. 
cases  of  cancer  and  of  carcinoma  of  at  Boston 
City  Hospital,  442. 
Breathing,  effect  of,  on  position  of  heart,  247-248. 

See  Respiration. 
Briggs,  Dr.  F.  M.,  cases  of  tuberculous  sinuses 

reported  by,  715-716. 
Brightness,  of  lungs,  in  X-ray  examination,  100. 

comparative,  of  lungs  in  tuberculosis,  119. 
Bromide  paper  for  X-ray  pictures,  57,  554. 
Bronchial   glands,  hypertrophied,  in  pulmonary 

tuberculosis.  119. 
Bronchitis,  200-201. 

excursion  of  diaphragm  in,  198. 
and  tuberculosis,  124,  140,  141-142. 
Broncho-pneumonia,  shadow  in  cases  of  192. 
Bronchus,  obstruction  of,  due  to  aneurism,  349. 
Brunettes,  skin  of,  reacts  less  quickly  to  X-rays, 

416. 
Bryant,    Dr.   Thomas,    on    X-ray    treatment    of 

stricture  of  rectum,  712. 
Bullets,  localization  of  by  X-rays,  531-532,  539. 

See  .Surgery,  military. 
Burn,  cause  of  so-called  X-ray,  447-448. 

curative  effect  of  X-ray,  421-422. 
Burns,   avoidable   in   therapeutic  use  of  X-rays, 

443- 
frequency  of  660. 
treatment  for,  661-663. 
Butterfly  lupus  erythematosus,  cases  of  405-406, 
714. 

C 

Calcification,  of  pleuritic  membrane,  233. 

of  tissues,  385-387. 
Calcium,  atomic  weight  of,  3,  4. 

phosphate  of,  radiograph  of  5. 

triphosphate  of  in  human  body,  3. 
Calculi,  4,  615-632. 

radiographs  of,  616,  619,  620. 
Calculus,  vesical,  radiograph  of.  618. 


73S 


INDEX 


Caldwell,  Eugene  W.,  new  tube  for  therapeutic 
examinations  described  by,  676. 
stereo-fluoroscopic   apparatus   employed   by, 

639- 
Callus,  new  and  old,  about  a  fracture,  490. 

radiograph  of,  516. 
Campbell,  Dr.  R.    R.,  on  treatment  of  acne   by 

X-rays,  671.  714. 
Cancer,  cases  of,  at  Boston  City  Hospital  for  a 
series  of  years,  441-442. 
epidermoid,  423,  684,  685. 
external  forms  of,  421.    See  u/so  New  growths, 
inoperable  cases  of,  440,  708-710. 
internal  forms  of,  710-712. 
of  band,  431-437- 
of  liver,  347. 

method  of  treatment  in  cases  of,  674-675. 
of  pylorus,  377. 
Cancers  of  the  breast,  420,  677,  702-710. 
Cannon,   Dr.  W.  B.,  observations  of  process  of 

digestion  by,  360,  372,  651-653. 
Capsules,  digestive  tract  observed  by  means  of, 

373- 
Carbon,  atomic  weight  of,  3. 
Carbonate  of  calcium,  radiograph  of,  5. 
Carbonate  of  magnesium,  radiograph  of,  5. 
Carbonate  of  sodium,  radiograph  of,  5. 
Carcinoma,  578.     See  also  New  growths. 

cases  of,  at  Boston  City  Hospital  for  a  series 

of  years,  441-442. 
of  the  breast,  421,  677,  702-708. 
epidermoid,  685-689. 
of  the  liver,  376-377. 
metastatic,  587. 
of  the  stomach,  376,  421. 
Cardiac  disease,  299. 
Cardiac  enlargement,  271. 
Caries  of  spine,  594,  596. 
Carotid  artery,  ligating,  in  aneurism,  317. 
Cartilage,  cricoid,  photographing  the,  89. 

loose,  of  joints.  X-ray  examinations  in,  556. 
radiograph  of,  599. 
Catgut,    radiograph    of    needle    threaded    with, 

472. 
Cathode  of  vacuum  tubes,  34. 
Cats,  Dr.  Cannon's  observations  of  stomachs  and 

intestines  of,  360,  372,  651-653. 
Cauterization,  hot  air,  for  lupus,  395. 
Cautery,  Faquelin's,  spread  of  lupus  after  use  of, 

406. 
Celluloid,   capsules   of,   for   observing    digestive 
tract,  373. 
use  of,  for  recording  fluorescent  screen  ap- 
pearances, 77. 
Cervix  femoris,  greenstick  fracture  of,  578. 
Cheek,  epithelioma  of,  689-690. 
Chemical  composition  to  be  considered  in  using 

X-rays,  7. 
Chest,  X-ray  examinations  of,  71,  74,   100,  102, 
354-355- 


Chest  {continued^  — 

dimensions   of,  determine  excursion  of  dia- 
phragm, 108. 

fluorescent  screen  best  for  examinations  of, 
109,  638,  651. 

foreign  bodies  in,  locating,  86. 

in   hydrothorax,   appearance    of,   on    screen, 
234. 

in  pleurisy,  appearances  in,  202-204. 

in  pneumothorax,  appearances  in,  234. 

time  of  exposure  for  photographing  the,  640. 

tracings  on  the,  79. 
Chest  wall,  new  growth  in,  345-346. 
Children,   articular  rheumatism  in,   relieved  by 
X-rays,  445-446. 

epiphyseal  lesions  in,  461. 

injuries  of  humerus  common  in,  467. 

observations  of  spleen  of,  374. 

obselvations  of  stomachs  of,  360-372. 

outline  of  liver  in,  373. 

Pott's  disease  in,  596. 

small  leftward  movement  of  heart  in,  301. 

time  for  taking  radiographs  of,  as  compared 
with  adults,  636. 

tuberculous  foci  on  spinal  column  of,  594. 

X-ray  examination  of,  384-385. 
Childs,  Dr.   S.   B.,   on   treatment  of  pulmonary 
tuberculosis,  715. 

on  treatment  of  tuberculous  glands,  716. 
Chloride  of  calcium,  risk  of  drying  static  machine 

with,  14. 
Chloride  of  potassium,  radiograph  of,  5. 
Chloride  of  sodium,  radiograph  of,  5. 
Chlorine,  atomic  weight  of,  3. 
Chlorosis,  displacement  of  heart  in,  297. 
Cholelithiasis,  radiographs  of  cases  of,  630. 
Cholera  vibriones,  experiments  with  cultures  of, 

450- 
Chondroma,  X-ray  examinations  of  service  in, 

556. 
Chondrosarcoma,  556,  583,  585. 
of  femur,  radiograph  of,  581. 
photograph  of,  580. 
Church,    Dr.   Archibald,   report    of,   concerning 

tumor  in  head,  340. 
Clapp,  Dr.  Dwight  M.,  ladiographs  of  teeth  by, 

608,  609,  610,  611,  613,  614. 
Classen,   Dr.,    account   by,  of  case   of  enlarged 
glands  simulating  the  outline  produced  by 
aneurism,  348-349. 
Clavicles,  appearance  of,  on  fluorescent  screen 
in  emphysema,  193. 
fractures  of,  at  Boston  City  Hospital,  456. 
normal  outlines  of,  on  screen,  102-103. 
position  of  plate  in  photographing,  482. 
radiograph  of,  104. 
Clitoris,  case  of  cancer  of,  at  Boston  City  Hos- 
pital, 442. 
Cloth  easily  penetrated  by  rays,  59. 
Clothing,  removal  of,  in  medico-legal  cases,  86. 


INDEX 


739 


Coccyx,   fractures  of,  at  Boston   City   Hospital, 
456- 

Codman,  E.  A.,  on  X-ray  burns,  660. 
on  X-ray  study  of  anatomy,  454. 

Coils,  static  machine  compared  with,  638-639. 

Colds  Ijordering  on  pneumonia,  192. 

Colon,  descending,  method  of  following  outline 
of,  358. 

Colonies,  bacterial,   effects  of  X-rays  on  devel- 
oped, 451. 

Comedones,  418,  670. 

Comparison,  of  static  machine   and  coils,  638- 

639- 
between  X-ray  photographs  and  screen  exam- 
inations.    See  Fluorescent  screen  examina- 
tions, 
of  X-ray  with  percussion  and  auscultation  de- 
terminations,     iice  Auscultation,    Percus- 
sion. 
Condenser  for  static  machine,  19. 
Congestion,  how  detected,  103. 
passive,  of  lungs,  307. 
pulmonary,  lack  of  brightness  in  lungs  due  to, 

308. 
shadows  on  fluorescent  screen  in,  158,  201. 
Consonants,  shape  of  palate  in  pronouncing  the, 

389- 

Constipation,   displacement  of  heart  in  antemia 
with,  297-298. 
size  of  heart  in  anaemia  with,  388-389. 

Contraction,  heart  displaced  by,  290-291. 

Contremoulin,  Dr.,  report  by,  of  radiographs  of 
muscles  of  animals,  466. 

Copper,  piece  of,  in  eye,  538-539. 

Cornea,  X-ray  treatn.ent  of  disease  of,  718-719. 

Corson,  Eugene  R.,  references  to  articles  by,  454, 
461. 

Cotton,  dressings,  86. 
radiograph  of,  472. 

Cough,   morning,  an  indication  of  tuberculosis, 
140. 

Councilman,    Dr.    \V.    T.,    164,    272,    433-435, 
436- 

Coxa,  vara,  575,  578. 
radiograph  of,  577. 

Coxitis,  value  of  X-rays  in,  594. 

Crayons  for  skin-tracings,  77-78. 

Cretinism,  disturbance  of  development  of  bones 
in,  461. 

Cretins,  development  of  skeleton  in,  461-462. 

Cricoid  cartilage,  photographing  the,  89. 

Crookes,  construction  of  vacuum  tube  by,  34. 

Cures,  of  diphtheria,  increase   in  percentage  of, 
160. 
possibility  of,  in  cases  of  pulmonary  tubercu- 
losis, 160. 

Curtain  for  hiding  static  machine,  93. 

Cashing,  Dr.  H.  W.,  report  by,  of  cases  of  regen- 
eration of  bones  after  operation,  562-564. 

Cvsts,  osseous,  use  of  X-ravs  in  cases  of,  722. 


D 

Dactylitis,  syphilitic,  597. 
Dampness,  removal  of,  from  plates,  14. 
Davidson,  J.  Mackenzie,  apparatus  for  locating 
foreign  bodies  devised  by,  533-535. 
radiographs  by,  578. 
report  by,  of  recognition  of  calculi  by  X-ravs, 

625. 
stereoscopic  fluoroscope  devised  by,  639. 
Davis,  Edward  P.,  photograph  of  gravid  uterus 

by,  382. 
De  la  Camp,  Dr.,  lack  of  result  in  treatment  of 
leprosy,  714. 
report  of  case  of  myositis  ossificans  by,  465-466. 
Densitometer,  105-106. 

Density,  contrasts  in,  offer  opportunity  for  X-ray 
examination,  377. 
in    lung,    an    obstruction    in    viewing    heart, 

247. 
in  lungs.  X-rays  indicate  increase  in,  306-307. 
of  lungs  in  pneumonia,  164-167. 
pulmonary.    X-ray    examination    an    aid    in 
showing,  191. 
Dent,  Dr.  C.  T.,  on  use  of  X-rays  in  fractures, 

468. 
Dental  surgery,  use  of  X-rays  in,  603-614. 
Depilation  produced  by  X-ray  exposure,  391,  416. 
Dermatitis  produced  by  exposure  to  X-rays,  391, 
409,  658-660. 
avoided  by  caution,  399. 
time  necessary  to  heal  a,  396. 
unnecessary  in  treatment  of  lupus,  393. 
Despeignes,  Dr.,  X-ray  treatment  of  carcinoma  of 

stomach  by,  421. 
Destot,  Dr.,  447. 

Development  of  X-ray  picture,  57. 
Dextrocardia,  case  of  apparent,  298. 

radiographic  examination  in  a  case  of,  650- 
652. 
Diagnosis,  in  pneumonia  made  certain  by  use  of 
X-rays,  183-186. 
more  than  one  X-ray  examination  often  neces- 
sary to  determine,  191. 
of  pulmonary  tuberculosis,  120-122,  124. 
of  pulpless  teetl\  611. 
X-ray  apparatus  a  help  to  a  definite,  355. 
See  Autopsy. 
Diagrams  of  X-ray  appearances  in  chest  in  — 
aneurism,  311. 
aortic  insufficiency,  299. 
emphysema  of  lungs,  104. 
health,  full  mspiration,  loi. 
heart  movements,  normal,  254. 
passive  congestion  or  oedema  of  lungs, 

307- 
pleurisy  with  large  effusion,  204. 
pleurisy  with  small  effusion,  203. 
pneumohydrothorax,  242. 
pneumothorax.  235. 
pulmonary  tuberculosis,  115. 


r40 


INDEX 


Diameter  of  heart,  errors  to  be  avoided  in  meas- 
uring, 263. 

relation  of,  to  height  of  individual,  261. 
Diameter  of  pelvis,  measurement  of,  379. 
Diaphragm  of  body,  appearance  of,  on  screen, 
100. 

depression  of,  due  to  aneurism,  349. 

displacement  of,  by  ascitic  fluid,  375. 

displacement  of  heart  by,  286. 

effects  of  position  of,  in  measuring  heart,  269. 

heart  rests  on,  during  expiraUon,  247. 

limitation  of  movement  of,  in  pneumonia,  171. 

outline  of,  in  pleurisy  with  effusion,  202. 

pneumonia  and  unequal  excursion  of,  288-290. 

position  of,  in  pneuuiohydrothorax,  245. 

position  of,  in  pneumothorax,  234. 

See  Excursion  of  diaphragm. 
Diaphragm  for  vacuum   tube,  47,  49-50,  52,  60, 

63.  95.  97.  604. 
Diaphysis  of  femur,  curvature  of,  578. 
Diastole,  experiments  on  form  of  heart  in,  253-257. 
Difference  of  X-ray  and   percussion  deteimina- 

tions  of  left  heart  border,  276-279. 
Diffraction  bands  by  X-rays,  1-2. 
Digestion,   physiology    of.    X-rays   a   means   for 
studying,  371-372,  651-653. 

size  and  position  of  stomach  during,  361-372. 
Dilatation,  aneurismal,  of  innominate  artery,  322. 

of  aorta   recognized   by   X-ray  examination, 
320. 

of  heart  by  exercise,  390. 
Diphtheria,  increased  percentage  of  cures  in,  160. 
Diphtheria  bacillus.  X-ray  experiments  with.  449, 

451- 
Disintegration  of  spinal  column,  578. 
Dislocation  of  hips  mistaken  for  coxa  vara,  578. 
Dislocations,  526-530. 
Displacement   of  heart,   iii,   167,  188,  204,  213, 

234,  279,  283-298,  647. 
Distension,  abdominal,  effect  of,  on  heart,  288. 
Diverticulum,  method  of  recognizing,  357-358. 
Dogs,  experiments  with  hearts  of,  255-256. 

observations  of  digestion  in  stomachs  of,  372. 
Dollinger,  Dr.,  418,  419. 

Dore,  Dr.,  on  Finsen's  concentrated  light  treat- 
ment of  lupus  and  rodent  ulcer,  444-445. 
Dorsalis  pedis  artery,  recognizing,  by  X-rav  pho- 
tographs, 387. 
Drainage  tube,  radiograph  of,  472. 
Dressings,  advantage  of  cotton,  in  taking  radio- 
graphs, 86,471,  473. 
Dried  egg  albumen,  radiograph  of,  5. 
Ductus  arteriosus  Botaili,  persistence  of  the,  301. 
Dyspepsia  a  symptom  of  tuberculosis,  162. 
Dyspnoea,  in  case  of  aneurism  of  aorta,  315,  322. 

in  case  of  emphysema,  195,  218. 

in  case  of  enlarged  glands,  347. 

in  case  of  interstitial  fibrous  pneumonia,  343. 

possible  cause  of  thoracic  aneurism,  313. 
Dvstrophy  of  bones,  721. 


Ear,  case  of  cancer  of,  at  Boston  City  Hospital, 
442. 

treatment  of  new  growths  in  the,  675. 
Eastman  paper  for  use  in  military  surgery,  554. 
Echinococcus,  of  lung,  346. 

of  liver,  373. 
Eclampsia,  photograph  of  uterus  in,  382. 
Eczema,  407-411,  669-670. 

Hahn    and    Albers-Schonberg's    conclusions 
concerning  X-ray  treatment  of,  411-412. 

treatment  of,  by  X-rays,  407-412,  669-670. 
Elbow,  fractures  of,  at  Boston  City  Hospital,  456. 

time  of  exposure  for  photographing  the,  640. 
, Elbow-joint,  photographing  fracture  of,  485-487. 

radiographs  of,  457. 

tuberculous,    treatment     of,    by   X-rays,    419, 

594- 
Electric  current  for  induction  coils,  8. 
Electrolytic  break,  Spottiswoode's,  20. 
Elements  of  human  body,  table  of  atomic  weights 

of,  3. 
Elephantiasis,  X-ray  treatment  of,  672. 
Ellsworth,  Dr.  Samuel  W.,  677. 
Embryology,  use  of  X-rays  in,  454. 
Emphysema,  an   aid  in    following   pulsations   of 
right  auricle,  252. 

association  of  tuberculosis  with,  140-141. 

displacement  of  heart  by,  647. 

enlargement  of  heart  due  to,  272. 

heart  drawn  down  in,  288. 

inferred  from  enlarged  heart,  283. 

of  the  lungs,  193-200,  262,  633. 

lungs  permeable  by  rays  in,  262. 

pleurisy  with  effusion  complicated  with,  218. 

pulmonary,  a  hindrance  in  heart-examination 
by  percussion,  198,  281. 

radiograph  of  case  of,  199. 

tuberculosis  symptoms  disguised  by,  124,  198, 
199. 
Empyema,  interlobar,  218. 

after  pneumonia,  192. 

suggested  by  darkened  lower  lung,  353. 

with  permanent  opening,  241. 

X-rays  an  assistance  in  recognizing,  353. 
Enlargement  of  heart,  167,  188,  262. 

chief  causes  of,  271-272. 
Ensiform  cartilage,  79. 
Epiphysis,  absence  of  union  of,  578. 

delayed  union  of.  459. 

dislocation  and  separation  of,  radiographs  of, 
528,  529. 

fracture  of,  radiograph  of,  521. 

separation  of,  at  lower  end  of  tibia,  radiograph 
of,  507.  508. 
Epithelioma,  of  hand,  431. 

of  lip,  430,  691. 
Epitheliomas  treated  by  X-rays,  440,  685-697. 
Epithelium,  growth  of,  stimulated  by  X-rays.  716. 
Equipment,  X-ray,  8-58,  636-640.    Sec  Apparatus. 


INDEX 


741 


Errors   to   be  avoided  in  X-ray  examination  of 

bones,  471. 
Erysipelas,  observation  of  cases  of  lupus  with,  393. 
Erythema,  in  case  of  eczema  of  beard,  415. 
from  short  exposures,  447. 
after  treatment  for  hypertrichosis,  417. 
Eve,  Frederick,  report  of  case  of  myositis  ossifi- 
cans traumatica  by,  465. 
Examination,  annual,  recommended,  309. 
of  bladder,  621. 
in  diseases  of  bones,  559. 
of  chest,  354-355,  643,  645. 
in  emphysema,  194,  647. 
fluorescent   screen,     .bftf   Fluorescent   screen 

examinations. 
in  fractures,  468-525. 
of  frontal  cavities,  464-465,  647. 
of  heart,  263-270,  649. 
of  joints  and  cartilages,  587. 
of  kidneys,  374,  617. 
of  lungs  in  pneumonia,  168. 
of  pneumothorax,  234. 
of  pneumohydro  or  pyothorax,  241-244. 
of  new  growths,  109. 
of  new  growths  in  thorax,  334-338. 
ordinary     physical,    incomplete    without    an 

X-ray  examination,  355. 
in  pleurisy  with  effusion,  205,  648-649. 
precautionary  X-ray,  147. 
preliminary,  with  fluorescent  screen,  99. 
of  teeth,  606. 

of  thoracic  aneurisms,  310. 
of  thorax,  76-77,  647-651. 
in  tuberculosis,  117-118. 
of  ureters,  619. 
of  X-ray  negatives,  96. 
Examinations,  comparison  of  X-ray,  with  percus- 
sion and  auscultation,  in  — 
diseases  of  heart,  272-283. 
pleurisy  with  effusion,  213,  217. 
pneumonia,  173,  183-186. 
tuberculosis,  149-151. 
tumors  in  chest,  339-343. 
X-ray,  as  supplement  to  palpation,  191. 
method  of  making  X-ray,  59-99.     See  Fluo- 
rescent screen  examinations. 
Excoriation  of  skin  by  X-rays,  392,  394. 
Excursion    of  diap'iragm,    affected  by  pleuritic 
adhesions,  229,  230. 
in  annemia,  388,  389. 
in  aortic  aneurism,  319. 
in  bronchitic  cases,  200. 
in  emphysema  of  lungs,  193. 
in  gangrene  of  lung,  351,  352. 
normal,  106. 

in  pneumonia,  167,  288-290. 
in  pulmonary  tuberculosis,  111-115. 
shortened  owing  to  a  severe  cold,  137. 
in  tuberculosis,  288. 
Exercise,  effect  of  excessive,  on  heart,  390, 


Exertion,  pain  in  side  after,  233. 
Exostosis,  556. 

luxurians,  466. 

radiograph  of  case  of,  586. 

of  ulna  and  radius,  radiographs  of,  588,  589. 
Expectoration  in  early  stages  of  pulmonary  tuber- 
culosis, 121-122. 
Experience   essential  in   using  X-ray  apparatus, 
446,  657-658. 

necessary  for  X-ray  diagnosis,  356. 
Experiments,   Forster   and    Hugi's,   with    radio- 
graphs, 546,  550. 

Ludwig  and  Hesse's,  253-257. 

Rollins',  with  guinea  pigs,  710-711. 
E.xpiration,  effect  of,  on  appearance  of  lungs  on 
screen,  100. 

incomplete,  due  to  enlarged  glanils,  349. 

position  of  heart  during,  247. 

See  Respiration. 
Exposure  of  plates,  62-64,  96-98,  640. 

in  photographing  bones  ;md  soft  tissues,  96. 

in  photographing  lungs,  108. 

in  photographing  teeth,  606-607. 

table  of  times  for,  640. 
Exudation,  eczema  with,  411,  66g. 
Eye,  localizing  foreign  body  in,  536-539,  719-720. 

new  growths  on  lid  of,  427-429,  675. 
Eyes,  adaptation  of,  to  dark  room,  75. 

method  of  deciding  whether  at  fault,  103-106. 

necessity  for  training,  in  use  of  X-rays,  103. 


Face,  cases  of  cancer  and  of  carcinoma  of,   at 
Boston  City  Hospital,  442. 
photographing  bones  of,  475. 
Fats  readily  traversed  by  rays,  3. 
Favus,  X-ray  treatment  for,  411-412. 

X-ray  treatment  for,  Freund  and  Schifif's,  414- 
416. 
Feilchenfeld,  Dr.,  report  of  case  of  spina  ventosa 

by,  562. 
Femur,  changes  in  neck  of,  578. 

chondrosarcoma  of,  radiograph  of,  581. 
coxitis  delays  ossification  of,  594. 
curvature  of,  diaphysis  of,  578. 
dislocation  of,  radiographs  of,  528,  529. 
fracture  of  left,  radiograph  of,  497,  498. 
photographing  fractures  of,  495-496. 
Femurs,  fractures  of,  at  Boston  City  Hospital,  456. 

fracture  of  both,  488-490. 
Fenwick,  Dr.,  method  of  of  examination  of  kidney 

outside  the  body,  621. 
Fever,  lack  of,  in  pneumonia  in  old  patients,  185. 
Fevvkes,  E.  E.,  635,  676. 
Fibrosis,  pulmonary,  displacement  of  heart  by, 

291. 
Fibula,  fractures  of,  radiographs  of,  504,  507,  508, 
511,  512,  520,  560. 
osteitis,  ladiograph  of,  560. 
periostitis  of  radiographs  of  558,  559. 


742 


INDEX 


Fibula  (continued)  — 

split  in,  and  fracture  of  tibia,  radiograph  of, 
Sio. 
Films,  development  of,  57. 
Finger,  glass  in,  radiograph  of,  550. 
spina  ventosa  of,  562. 
diseased,  radiographs  of,  582,  583. 
tumor  of,  radiograph  of,  585. 
Finger-nails,  effect  of  X-rays  on,  393,  659. 
Fingers,  fractures  of,  at  Boston  City  Hospital,  456. 

photographing  the,  98. 
Finsen's  light  treatment,  for  bacteria,  452. 
of  lupus,  407. 
of  rodent  ulcer,  444-445. 
Fiorentine,  Dr.,  experiments  of,  with  X-rays  and 

animals  inoculated  with  bacteria,  453. 
Flesh,  transparent  to  X-rays,  2. 
Fluid,  in  thorax,  353. 

pleuritic,  213,  230,  285-286,  648-649. 
serous,  205. 
Fluorescent  screen,  of  assistance  to  surgeon  in 
connection  with  radiograph,  455. 
importance  of,  in  diagnosis  of  aneurism,  328. 
localization  of  foreign  bodies  by,  531-532. 
value  in  studying  pulmonary  tuberculosis,  in. 
Fluorescent  screen  appearances,  in  bronchitis,  200. 
in  case  of  apparent  dextrocardia,  298. 
in  emphysema,  193,  647. 

in  heart-examinations,  247,  262,  270,  285-288. 
in  hydrothorax,  234. 

in  pleurisy  with  effusion,  202-205,  648-649. 
in  pneumothorax,  234. 
in  pneumohydrothorax,  241,  243,  647-648. 
in  pneumonia,  164-180. 
Fluorescent  screen  examinations,  for  calculi,  617. 
comparison  between  X-ray  photographs  and, 
in  — 

dextrocardia,  650-652. 
early  tuberculosis,  120. 
fractures,  99. 
heart-diseases,  270. 
localization  of  foreign  bodies,  99,  554. 
pleurisy,  205. 
pneumonia,  169-173. 
study  of  thorax,  99. 
of  heart,  247-253,  257-270. 
of  oesophagus,  357. 
rules  for,  74-77. 
Fluoride  of  calcium,  radiograph  of,  5. 
Fluorine,  atomic  weight  of,  3. 
Fluorometer,  640-642. 
Fluoroscope,  56.     See  Fluorescent  screen, 
stereoscopic,  639. 

use  of,  in  case  of  dextrocardia,  651. 
FcEtus,  determining  size  and  position  of,  382-383. 

photograph  of,  459. 
Food,  length  of  stay  in  stomach,  372-373. 

stomach  should  be  free  from,  for  examination, 

360. 
tracings  of  stomach  containing,  361-371. 


Foot,   cases   of  cancer  and  of  carcinoma  of,  at 
Boston  City  Hospital,  442. 

chronic  swelling  of,  522. 

flat,  598,  601. 

fractures  of,  at  Boston  City  Hospital,  456. 

method  of  photographing,  89,  522-525. 

radiographs  of,  523,  524,  552. 

time  of  exposure  for  photographing,  640. 

tuberculosis  of,  587,  591,  592. 
Forearm,  fractures  of,  at   Boston  City  Hospital, 
456. 

photographing  the,  93,  640. 

radiograph  of  dislocation  of  both   bones  of, 

527- 
tumors  on.  X-ray  examination  of,  596. 
Foreign  bodies,  in  air  passages,  200. 

device  for  withdrawing,  from   stomach,  720- 

721. 
fluorescent  screen  sometimes  best  for  studying, 

99.  455- 
localization  of,  81-86,  454,  531-552,  719-721. 
necessity  for  taking  two  views  of,  98. 
Forster,  account  by,  of  experiments  in  detecting 

pieces  of  metal  by  radiographs.  546-550. 
Fox,  Dr.  L.  Webster,  localizer  of  foreign  bodies 

in  eye  devised  by,  719-721. 
Fracture,  greenstick,  of  cervix  femoris,  578. 
mistaken  for  bowed  leg,  522. 
of  ulna,  481. 
Fractures,  in  children,  use  of  X-rays  in,  384. 
necessity  for  taking  two  views  of,  98. 
radiograph  of,  preferable  to  screen  examina- 
tion, 99. 
radiographs  of.    See  Radiographs  of  fractures, 
records  of  cases  at  Boston  City  Hospital,  455, 

456- 
use  of  X-rays  in  gunshot,  554-555. 
X-rays  used  in  studying,  454,  467-524. 
Frei,  construction  of  vacuum  tube  by,  34. 
Freund,  on  apparatus  for  therapeutic  uses,  394. 
on  Finsen's  concentrated  light  treatment,  407. 
on  frequency  of  sittings,  402. 
on  recurrence  of  lupus  after  X-ray  treatment, 

398. 
on  treatment  of  acne  and  comedones,  418. 
on  treatment  of  alopecia  areata,  673. 
on  treatment  of  hypertrichosis,  391,  417. 
on  treatment  of  neuralgia,  663. 
on  treatment  of  sycosis  and  favus,  414-416. 
on  Trendelenburg  position  for  photographing 

pelvis,  379. 
use   of  X-ray   photography    by,  in    fractures, 
522. 
Fripp,  Dr.,  recognition  of  calculus  by  X-rays,  623.      , 
Frog,  experiments  with  X-rays  on  heart  of  449- 

450- 
Frogs,  observations  of  digestion  in  stomachs  of, 

372. 
Frontal  cavities.  X-rays  an  aid  in  examining,  464- 
465,  647. 


INDEX 


743 


Gall  bladder,  calculi  in,  615. 

cases  of  cancer  of,  at   Boston  City  Hospital, 
442. 
Gallois,  E.,  work  by,  on  X-ray  treatment  of  frac- 
tures, 468. 
Gall  stones,  445,  630. 

radiograph  of,  616. 
Gangrene  of  lung,  351-352. 
Gardette,  Dr.  Victor,  on  use  of  radiography  in 

disease  of  hip  joint,  721-722. 
Gas,  introduction  of,  into  hollow  organs,  358. 
liberation  of,  from  terminals  and  walls  of  vac- 
uum tube,  42-45. 
in  pleura?,  effect  on  heart  of,  285-286. 
Gases  almost  wholly  transparent  to  rays,  4. 
Gassmann,  on  changes  produced  in  skin  by  X- 
ray  treatment,  396,  447. 
on  recurrence  of  lupus,  398. 
treatment  of  sycosis  by,  416. 
Gautier,  Dr.,  on  treatment  of  acne  by  X-rays,  670- 

671. 
Gelatin,  radiograph  of,  5. 
Generators,  636. 
Genoud,  experiments  by,  with  X-rays  and  animals 

inoculated  with  bacteria,  452-453. 
Gibson,  George  Hamilton,  method  of,  for  remov- 
ing foreign  bodies  from  oesophagus,  720. 
Girdwood,  G.  P.,  method  of  locating  foreign  bod- 
ies devised  by,  533. 
use  of  stereoscopic  pictures  by,  457,  471. 
Glands,  enlarged,  347-351. 

tuberculous,  715. 
Glass,  best  material  for  plates  of  static  machine, 
10. 
in  finger,  radiograph  of,  550. 
obstacle  to  passage  of  rays,  40,  41. 
tracing  outlines  of  heart  on,  264. 
use  of,  for  recording  appearances,  77. 
Glycerine,  radiograph  of,  5. 
Gocht  on  therapeutic  uses  of  X-rays,  393, 395,  398, 

406,  417,  420,  421,  448. 
Godlee,  R.  J.,  reports  of,  on  changes  in  neck  of 

femur,  578. 
Goitre  with  enlarged  thyroid,  714. 
Goodspeed,  A.  W.,  radiographs  by,  594,  637. 
Gorl,    Dr.,   recognition    of    calculus   by   X-rays, 

623. 
Gout,  cartilages  affected  by,  598. 
Gravid  uterus,  382. 

Greenleaf,  Dr.  Clarence  A.,  on  therapeutic  treat- 
ment of  lupus  vulgaris  by  X-rays,  713. 
Groin,  cases  of  cancer  and  of  carcinoma  of,  at 

Boston  City  Hospital,  442. 
Grossman's   localizer  of  foreign  bodies  in   eye, 

536-537. 
Growths,  localization  of  foreign,  81-86. 

new,  use  of  fluorescent  screen  in  determining 

position  of,  109.     See  New  growths. 
Grunmach,  Dr.,  356,  663. 


Guinea  pigs   inoculated  with  bacteria,  effect  of 
X-rays  on,  452. 
Rollins'  experiments  with,  to  ascertain  effect 
of  X-rays  on  cell  growth,  710-711. 
Gussenhauer,  Dr.,  587. 

H 
• 

Hahn,  on  therapeutic  uses   of  X-rays,  392,  393, 

397.  398,  406,  407-409,  411-412,  418,  668, 

671. 

X-ray  study  of  syphilitic  diseases  by,  596. 

Hair,  removal  of,  in  treating  sycosis  and  favus, 

414.     See  Hypertrichosis. 

effect  of  X-rays  on  growth  of,  672-673. 

Hand,  cancer  of,  431-433. 

cases  of  cancer  and  of  carcinoma  of,  at  Boston 

City  Hospital,  442. 

congenital  malformation  of,  462,  463. 

epithelioma  of,  431-433. 

fracture  of,  at  Boston  City  Hospital,  456. 

needle  in,  545,  546,  547. 

photograph  of,  584. 

photographing  the,  93,  98,  640. 

Hansmann,  Frida,  on  resistance  of  vacuum  tube, 

655. 
Harris,  L.  Herschel,  on  X-ray  treatment  of  hyper- 

trophied  scar  tissue,  712. 
Harrison's  localizer  of  foreign  bodies,  535-536. 
Harvey,  opinion  of,  on  shape  of  heart  in  systole, 

254- 
Haughton  quoted  concerning  use  of  X-rays  in 

military  surgery,  553. 
Hawkes,  H.  D.,  on  so-called  X-ray  burn,  447. 
Head,  eczema  of,  treatmeirt  of,  by  X-rays,  408. 
examination  of,  for  fracture,  475. 
position  of  plate  and  tube  in  photographing, 

88. 
time  of  exposure  for  photographing,  640. 
tumors  in,  340,  645-647. 
Healing,  process  of,  in  lupus  cases,  395-396. 
Heart,  247-309,  649. 

appearance  of,  in  emphysema,  193. 
appearance  of,  on  fluorescent  screen,  100. 
best  time  for  measuring,  248-249,  253. 
displacement  of,  283-298. 

in  emphysema,  647. 

in  pleurisy,  204,  213,  291. 

in  pneumonia,  167,  188. 

in  pneumothorax,  234,  235. 

in  pulmonary  tuberculosis,  in. 

not  recognized  by  percussion,  279. 
examination   of,  by  auscultation   and  percus- 
sion, 162,  282. 
examination  of,  by  X-rays,  247,  262,  270,  285, 

288. 
experiments  by  Ludwig  and  Hesse  on  form 

of,  253-257. 
fatty,  271. 
murmurs,  301,  305. 
normal,  247-283. 


744 


INDEX 


Heart  {cotitinued')  — 
overtaxing  tiic,  309. 
photographing  the,  93-95,  270. 
pleuritic    adhesions    shown    by   displacement 

of.  233. 
position  of,  affected  by  new  growths  in  abdo- 
men, 375-376. 
position  of,  in  pulmonary  tuberculosis,  119. 
size  of,  270-283. 
size  of,  in  ana?mia,  388. 
size  and  position  best  determined  by  X-rays, 

633- 
weights  compared  with  widths,  273-275. 
width  of,  in  mitral  insufficiency,  304. 
width  of  normal,  260. 
Heart  sounds,  hearing  the,  17,  93. 
Hearts  of  dogs,  e.vperiments  with,  255-256. 
Hedlev,  \V.  S.,  account  by,  of  method  of  locating 

foreign  bodies,  533-535- 
Height  of  individual,  width  of  heart  in  relation 

to,  261. 
Heinze  electrolytic  interrupter,  21,  22,  25,  637. 
Herman,  Dr.,  recognition  of  calculi  by  X-rays, 

624-625. 
Herpes  zoster.  X-ray  treatment  of,  666. 
Hesse,  experiments  by,  on  form  of  heart,  253-257. 
Hip,  case  of  carcinoma  of,  at  Boston  City  Hos- 
pital, 442. 
disease,  use  of  X-rays  in,  384. 
time  of  exposure  for  photographing  the,  640. 
tuberculosis  of,  radiograph  of,  593. 
Hip  joint,  disease  of,  721-722. 

photographing  the,  493-495. 
Hips,  dislocation  of,  mistaken  for  coxa  vara,  578. 
Hoarseness,  aneurism  indicated  by,  323,  324. 
Hodgkin's  disease,  X-ray  treatment  of,  717-718. 
Hoffmann,  Dr.,  investigations  by,  on  movements 

of  the  heart,  301,  304-305. 
Hofmeister,  Dr.,  on  disturbance  of  development 

of  bones  in  cretinism,  461. 
Holder,  for  pencil  in  skin  tracings,  77. 

for  vacuum  tube,  47-55,  604,  605,  643,  655. 
Holland,  Dr.  Thurston,  on  treatment  of  lupus  by 

X-rays,  713. 
Holtz  influence  machine,  8,  637. 

necessity  of  case  for,  14. 
Holzknecht,  G.,  X-ray  treatment  of  alopecia  areata 

by,  673. 
Horsehair,  radiograph  of  needle  threaded  with, 

472. 
Hugi,  account  by,  ot   experiments   in    delecting 

pieces  of  metal  by  radiographs,  546-550. 
Humerus,  fractures  of,  radiographs  of,  476-479. 
osteosarcoma  of,  radiograph  of,  579. 
tumor  of,  use  of  X-rays  in  treating,  596. 
Hyde,  Dr.,    therapeutic   use  of  X-rays   by,  662, 

668-669,  671-672,  674. 
Hydrocele  fluid  and  water,  experiment  with,  6. 
Hydrogen,  atomic  weight  of,  3. 
Hydrothorax,  234. 


Hyndman,  H.  H.  F.,  I,  2. 
Hyoid  bone,  cut  of,  88. 

photographing  the,  89. 
Hyperceniia,  in  case  of  sycosis  of  beard,  415. 
caused  by  short  exposures,  447. 
inclination  to,  diminished  by  vaseline,  397. 
Hypertrichosis,  treatment  of,  by  X-rays,  391,  416- 

417. 
Hypertrophies,  X-ray  treatment  of,  672. 
Hypertrophy  of  bone  and  cartilages,  556. 
Hyposulphite  of  soda   solution,  for  fixing  nega- 
tives, 58. 
Hysteria,   difference   of   X-ray    and    percussion 
determinations   of  heart   border   in  cases 
of,  278. 

I 
Imbert,  Dr.,  on  study  of  articular  movement  by 

X-rays,  389. 
Immelman,  Dr.,  446. 
India,  X-ray  apparatus  in,  553. 
Induction  coils,  8,  19-31,  637-639. 
Inexperience,  danger  of,  in  X-ray  examinations, 

356,  657-658. 
Inflammation,    condition    of    pleurae    following, 
229. 
hair   regarded   by   Freund    and   Schiff  as   a 

source  of,  414. 
of  skin  by  exposure  to  X-rays,  391. 
Inflammations,  treatment  of,  by  X-rays,  666-672. 
Influence  machines,  8. 

Influenza  accompanied  by  pneumonia,  191-192. 
Innominate  artery,  ligating  the,  in  aneurism,  317. 
Inspiration,  deep,  best  time  for  measuring  heart, 
248-249,  253. 
effect  of,  on  appearance  of  lungs  on  screen, 

100,  248. 
movement  of  heart  during,  247-248. 
movement  of  heart  during,  in  tuberculosis,  288. 
See  Respiration. 
Insulation,  of  patients  under  X-ray  treatment, 

395- 

of  static  machine,  10. 
Intensifying  screens,  96,  120,  639. 
Interpretation  of  X-ray  pictures,   importance  of 

correct,  89,  356,  613-614,  634. 
Interrupters  for  coils,  20-22,  24,  637-639. 
Intertrigo,  use  of  X-rays  in,  666. 
Intestine,  cases  of  cancer  of,  at  Boston  City  Hos- 
pital, 442. 

methods  of  observing  large,  358. 
Intestines,  378. 

movement  of  food  through,  370,  651-653. 
Iodide  of  potassium  injected  in  empyema,  241. 
Iodine  for  removing  skin  tracings,  532. 
Iodoform,  bandage,  radiograph  of,  472. 

injected  in  empyema,  241. 

opacity  of,  to  X-rays,  86,  473,  474. 
Iron,  amount  of,  in  blood,  6. 

atomic  weight  of,  3. 
Itching,  eczema  with,  411. 


INDEX 


745 


J 

Jankau  on  mode  of  action  of  X-iays,  393. 
Jaw,  cases  of  cancer  and-of  carcinoma  of,  at  Bos- 
ton City  Hospital,  442. 
fractures  of,  at  Boston  City  Hospital,  456. 
necrosis  of  lower,  radiograph  of,  561. 
Jedlicka,  R.,  radiographs  by,  457  n. 
Johnson,    Dr.,  on  iise  of  X-rays  in  carcinoma, 

421-422,  695,  701. 
Joints,  of  children  easily  photographed,  387. 
diseases  of  the,  556,  583-602. 
method  of  examining,  by  X-ravs.  587. 
radiographs  of,  457. 
swollen,  458. 
julliard,  G.,  recognition  of  calculus  by  X-rays, 

626. 
Jutassy,  Dr.,  on  charges  produced  in  skin  by  ex- 
posure to  excited  vacuum  tube,  447. 
on  X-ray  treatment  of — 
acne,  418. 
eczema,  409. 
hypertrichosis,  416-417. 
lupus,  398,  405-406. 
naevus  flammeus,  412-413. 


Kaposi,  Dr.,  on  changes  produced  in  skin  by  ex- 
posure to  excited  vacuum  tube,  447. 
Katzenstein,  radiographs  by,  597. 
Keratosis,  X-ray  treatment  of,  672. 
Kibby,  on  changes  produced  in  skin  by  exposure 

to  excited  vacuum  tube,  447. 
Kidney,  photographing  the,  640. 

radiograph  of,  620. 
Kidneys,  calculi  in,  615. 

X-ray  examinations  of,  374,  617. 
Kienbock,  Dr.  R.,  description  of  X-ray  dermatitis 
by,  658-660. 
treatment  of  alopecia  areata  by,  673. 
Klondike  adventurer  with  enlarged   heart,  308- 

309- 
Knee,  fractures  of,  at  Boston  City  Hospital,  456. 

photograph  of,  580. 

photographing  the,  89,  499,  640. 
Knee-joint,    loose   cartilages    in,   radiograph    of, 

599- 
syphilitic  diseases  of,  596-597. 
Kratzenstein,  G.,  452,  457  n. 
Kiimmell,  on  Finsen's  light  treatment,  407,  452. 
on  X-ray  treatment   of  lupus,  393,  394,  395, 

398,  406. 

L 
"  La  grippe,"  pneumonia  with,  191-192. 
Lambertz,  X-ray  photographic  work  of,  459. 
Lancashire,  Dr.  G.  H.,  on  X-ray   treatment   of 

rodent  ulcer,  694-695. 
Lane,  Dr.,  report  by,  of  cases  of  deficiency  of 

bone,  462. 
Lannelongue,  Dr.,  report  by,  of  use  of  X-rays  in 

a  case  of  tuberculosis  of  bones,  592. 


Larynx,  cases  of  cancer  and  of  carcinoma  of,  at 
Boston  City  Hospital,  442. 

ossification  of  cartilage  of,  462. 

papilloma  of,  700. 

plates  for  photographing,  88. 

tuberculosis  of  the,  418. 
Lauenstein,    Dr.,    recognition    of    calculus    by 

X-rays,  624. 
Lawrence,  R.  R.,  26-27,  538,  642. 
Leather  transparent  to  X-rays,  2. 
Leg,   cases   of  cancer  and   of  carcinoma   of,  at 
Boston  City  Hospital,  442. 

fractures  of  bones  of,  501. 

fractures   of  both   bones   of,  radiographs  of, 
505.  506,  509,  516-519. 

fracture  of,  mistaken  for  bowed,  522. 

fractured,  taking  radiograph  of,  89,  91,  92. 

fractures  of,  at  Boston  City  Hospital,  456. 

time  of  exposure  for  photographing,  640. 
Legs,  eczema  in,  407-408. 
Leigh,  Southgate,  419,  445. 
Leo,  H.,  on  case  of  tumor  in  chest,  339. 
Leonard,  Dr.,  recognition  of  calculi  by  X-rays, 

622,  627-629,  630,  631. 
Leprosy,  X-ray  treatment  of,  714. 
Lesions,   character   of  bone,   shown   by  X-rays, 

554-555- 
epiphyseal,  461. 
of   tuberculosis,   old.   X-ray   examination   of 

value  in,  124,  148-149. 
valvular,  as  cause  of  enlarged  heart,  271,  283. 
Letters,  brass,   for   identification   of  position  of 

negative,  87,  634. 
Leucocytes,  effect  of  X-rays  on,  449-450. 
Leucocytosis,  absence  of,  in  some  cases  of  influ- 
enza, 192. 
Level,   use   of  a,   in    posing    patient    for    heart 

examination,  247. 
Levy,  Alfred  G.,  report  by,  of  arrested  develop- 
ment of  ribs,  463. 
Levy-Dorn,   on   detection   of  small   tuberculous 
foci  by  radiographs,  594. 
on  echinococcus  of  the  lung,  346. 
observation  of  digestive  tract  by,  373. 
study  of  heart  by,  249,  261. 
Lichen  ruber  planus,  treatment  of,  by  X-rays,  672. 
Life   insurance  examinations,  use  of  X-rays  in, 

633-634- 
Ligaments,  length  of  exposure  for,  96. 
Light,  adjustment  of  static  machine  for  varying, 
16,  22. 
amount  necessary  for  photograph  and  screen, 

47- 
for  developing  X-ray  pictures,  57-58. 
method  of  testing  quality  of,  46,  640-642. 
penetrating  power  of,  46. 
treatment,    Finsen's    concentrated,   407,   444- 

445.  452- 
Linaschi,  experiments  of,  with  X-rays   and   ani- 
mals inoculated  with  bacteria,  453. 


746 


INDEX 


Lindermann,  method  of,  for  observing  stomach, 

359- 
Lip,  cases   of  cancer  and   of  carcinoma   of,  at 

Boston  City  Hospital,  442. 
epithehoma  of,  430. 
Liquids,  length  of  stay  of,  in  stomach,  372. 
Little,  Muirhead,  on  coxa  vara,  575,  578. 
Liver,  cancer  of,  347,  442. 
carcinoma  of,  376-377,  442. 
displacement  of,  in  pleurisy  with  effusion,  204. 
echinococcus  of  the  lung  arises  from,  346. 
observation  of,  by  X-rays,  373. 
Localization  of  foreign  bodies,  metliods  of,  81-86, 

531-538,  719-721. 
Localizers  of  foreign  bodies,  533-538,  719-720. 
Location  of  static  machine,  15. 
Lodge,  arrangement  of  vacuum  tube  by,  35. 
Loison,  Edward,  suggestion  by,  of  employment 

of  Eastman  paper  in  military  use  of  X-ray 

photography,  554. 
Longard,  Dr.,  recognition  of  calculi  by  X-rays, 

626. 
Lortet,  Dr.,  experiments  of,  with  X-rays  and  ani- 
mals inoculated  with  bacteria,  452-453. 
Lothrop,  Dr.  H.  A.,  on  cases  of  frontal  sinus,  647. 
Lucas,  R.  C,  report  of  case   of  localization   of 

bullet  by,  539. 
Ludwig,  experiments  by,  on  form  of  heart,  253- 

257- 
Lung,  abscess  of,  351-352. 

cases  of  cancer  and  of  carcinoma  of,  at  Boston 
City  Hospital,  442. 

echinococcus  of,  346. 

gangrene  of,  351-352. 

new  growth  in,  332. 
Lungs,  abnormal-,  103,  160. 

apices  of,  comparison  of,  75-76,  102. 

apices  of,  examination  of,  102,  134-135. 

appearance  of,  on  screen,  100. 

appearance  of,  on  screen  in  early  tuberculosis, 

"5- 

cavities  in  the,  157-158. 

clearness  in,  necessary  to  determine  borders 
of  heart,  247. 

crowding  of,  by  diaphragm  or  abdomen,  288. 

emphysema  of  the,  193-200,  633,  647. 

examination  of,  by  auscultation  and  percus- 
sion, 162. 

examination  of,  in  pneumonia,  168. 

examination  of,  when  tuberculosis  is  in  some 
other  portion  of  body,  147. 

oedema  of,  158. 

oedema  of,  in  renal  diseases,  374-375. 

photographing  the,  93-95. 

of  pneumonia  patient  (cuts),  165,  166. 

region  usually  affected  in  pneumonia,  167-168. 

transparency  of,  to  rays  during  deep  inspira- 
tion, 248. 

tuberculosis  in,  in  cases  of  pleurisy,  222-229. 

use  of  densitometer  on,  106. 


Lungs  (continued)  — 

X-rays  readily  traverse,  100. 

Lupus,  therapeutic  use  of  X-rays  in  treatment  of, 
391.  394-407,  411-412,  420,  712-713. 

Lupus  erythematosus,  404-406,  713-714. 

Lupus  vulgaris,  394-395,  712-713. 

Lymphadenitis,  347-349. 

Lymph  glands,  case  of  tumor  arising  from  medi- 
astinal, 339. 

Lymphomata  colli,  417. 

M 

Macalister,  Donald,  quoted  on  form  and  mechan- 
ism of  heart,  253-257. 
jVIcArthur,  Dr.,  recognition  of  calculus  by  X-rays, 

623-624. 
McBurney,  Dr.,  recognition  of  calculus  by  X-rays, 

626. 
McCaw,  Dr.  James  Francis,  treatment  of  primary 

epithelioma  by,  696-697. 
Mclntyre,  Dr.,  recognition  of  calculus  by  X-rays, 

623. 
Magnesium,  atomic  weight  of,  3. 
Magnesium  ammonium   phosphate,   radiograph 

of,  5. 
Malformations,  463-465. 
in  children,  384. 
of  pelvis,  378-379. 
Mallory,   Dr.,  examination  of  new  growths  by, 
424,  429,   430,   431-433.  434-435.  436-437. 
439.  440,  684. 
Mask  for  face  in  lupus,  400,  446. 
Mayou,    Stephen,    device    of,    for   withdra\\ing 

foreign  bodies  from  stomach,  720-721. 
Measles,  bronchitis  following,  201. 
Measurement  of  heart,  248-249,  253. 

faulty  method  of,  265-270. 
Medico-legal  use  of  X-rays,  86,  633-634. 
Membrane,  pleural,  fluid  enclosed  in,  218. 
Men,  average  weight  of  heart  in,  273-275. 

heart  more  to  the  right  in,  than  in  women, 

260. 
position  of  nipples  of,  261. 
Meningitis,  difference  of  X-ray  and  percussion 
determinations  in  cases  of,  277. 
tuberculous,    examination    of    patients    with 
symptoms  suggesting,  385. 
Merrill,  Dr.,  on  use  of  X-rays  in  carcinoma,  421- 

422,695,701. 
Metacarpal  bones,  fracture  of,  467,  491-492. 
radiographs  of  fractures  of,  492,  494,  495. 
Metal,  experiments  with  radiographs  of,  550. 
necessity  of  removing,  in  taking  radiographs, 
86. 
Metals,  X-rays  absorbed  by,  2. 
Metatarsus,  radiograph  of  subdislocation  of,  530. 
Mice   inoculated  with  bacteria,  effect  of  X-rays 

on,  452. 
Milk  sugar,  radiograph  of,  5. 
Mill  board,  radiograph  of,  472. 


INDEX 


747 


Mills,  Dr.  Charles  K.,  report  by,  of  localization 

of  tumors  of  brain  by  X-rays,  645-646. 
Mink,   experiment  of,   with   typhoid   bacilli  and 

X-rays,  448. 
Miti-al  insufificiency,  width  of  heart  in,  304. 
Mitral  valve,  excursion  of  heart  in  insuliiciency 

of,  299. 
Mobility  of  heart,  301. 

Moisture  on  plates,  precautions  against,  14,  636. 
Molin,  Henri,  study  of  dystrophy  of  bones  by,  721. 
Mongour  reports  negative  results  with  X-rays  in 

phthisis,  418. 
Montgomery,  Dr.,  on  therapeiuic  uses  of  X-rays, 

662,  668-669,  671-672,  674. 
Morning  cough  an  indication  of  tuberculosis,  140. 
Morris,  on  Finsen's  light  treatment  of  lupus  and 

rodent  ulcer,  444-445. 
Morrison,  Rutherford,  recognition  of  calculus  by 

X-rays,  627. 
Morton,   Dr.  C.  A.,  recognition   of  calculus  by 

X-rays,  624. 
Mottling  of  lung  in  X-ray  photograph,  117. 
Mouth,  cases  of  cancer  of,  at  Boston  City  Hos- 
pital, 442. 
treatment  of  new  growth  in  the,  675-676. 
Movement  of  heart  during  respiration,  247-248. 

of  stomach  during  respiration,  362-363. 
Miihsam,  experiments  of,  with  X-rays  and  animals 

inoculated  with  bacteria,  452. 
Mtiller,  Dr.,  recognition  of  calculus  by  X-rays,  627. 
Munro,  Dr.  John  C,  use  of  X-ray  photography 

in  localization  of  Inillet  in  head  by,  539. 
Murmurs  of  heart,  301,  305. 
Murray,  on  use  of  X-rays  in  acromegalia,  578. 
Muscle,  examination  of,  by  X-rays,  465-466. 

length  of  exposure  for,  96. 
Mycosis  fungoides,  treatment  of,  by  X-rays,  714. 
Myocarditis,  pulsations  of  heart  in,  298. 
.    X-ray  examination  of,  305-306. 
Myositis  ossificans,  465. 


Nmvus  ilammeus,  X-ray  treatment  for,  412-413. 

Nails,  effect  of  X-rays  on,  393,  659. 

Neck,  cases  of  cancer  and  of  carcinoma  of,  at 

Boston  City  Hospital,  442. 
Necrosis  of  bone,  radiograph  of,  482. 

of  lower  jaw,  radiograph  of,  561. 
Needle,  in  hand,  radiographs  of,  545,  546,  547. 

in  OS  calcis,  543-544- 
Needles,  precautions  concerning,  545-546. 
Negative,  aids  to  interpretation  of  the,  87. 

method  of  examining,  96,  98. 

necessity  for  more  than  one,  96. 

relative  usefulness  of  screen  and,  in  examina- 
tions of  thorax,  108. 

value  of,  in  surgery,  457. 
Negatives,  X-ray,  compared  with  photographs,  96. 
Nephritis,  as  cause  of  enlarged  heart,  271-272. 

chronic  diffuse,  374. 


Nerve  structures,  action  of  X-rays  on,  664. 
Nervous  system,  effect  of  disturbance  "of,  on  di- 
gestion, 372. 
Neuralgia,  aneurism  suggesting  intercostal,  319- 
320. 
caused  by  unerupted  teeth,  use  of  X-rays  for, 

607-608 . 
suggested  by  cases  of  aneurism,  313. 
trigeminal,  X-ray  treatment  for,  420,  663. 
use  of  X-rays  in,  663. 
New  growths,  332-347,  674-714. 
in  abdomen,  375-378. 
changes  in  outline  of  heart  due  to,  262. 
obstruction  of  trachea  by,  200. 
in  thorax,  distinguishing  between,  and  aneu- 
rism, 312. 
treatment  of,  by  X-rays,  420-444,  674-714. 
which  interfere  with  bony  structure,  578. 
Night    sweats    an    indication    of    tuberculosis, 

140. 
Nipples,  variation  in  distance  between,  261. 
Nitrate  of  silver  for  marking  position  of  foreign 

bodies,  532. 
Nitrogen,  atomic  weight  of,  3. 
Norton,  Charles  L.,  26-27,  SS^. 
Norton  and  Lawrence  apparatus,  26-27. 
Nose,  cases  of  cancer  and  of  carcinoma   of,  at 
Boston  City  Hospital,  442. 
epithelioma  of,  687. 
lupus  of,  394-395.  406-407. 
Nutshell,  pneumonia  caused  by  swallowing,  200. 

O 

Observation,  necessity  of  correct,  of  X-ray  ap- 
pearances, 99,  356. 

GLdema.  of  the  lungs,  158,  307. 
in  renal  disease,  374. 

Qisophagus,  aneurism  of  aorta  with  perforation 
into,  315-317. 
cases  of  cancer  of,  at  Boston  City  Hospital, 

442. 
foreign  bodies  in,  539-541,  720. 
method  of  rendering  outline  of,  visible  on  fluo- 
rescent screen,  357. 
stricture  of,  313,  315-317.  323-324.  357- 

Olecranon,  radiograph  of  fracture  of,  479,  480. 

Oleic  acid,  radiograph  of,  5. 

Oilier,    report   by,   of  cases    of  regeneration    of 
bones  after  operation,  562. 

Omentum,  case  of  cancer  and  of  carcinoma  of, 
at  Boston  City  Hospital,  442. 

Opening,  permanent,  empyema  with,  241. 

Operation,  use  of  X-rays  instead  of,  708. 

Ophthalmoscope    for    verifying    localization    of 
foreign  body,  537. 

Ormsbv,  Dr.,  on  therapeutic  uses  of  X-rays,  662, 
668-669,  671-672,  674. 

Os  calcis,  needle  in,  543-544. 

Oschmann,   A.,   on   the   operative    treatment   of 
tuberculous  elbow-joints,  594. 


748 


INDEX 


Ossification,  of  cartilage  of  larynx,  462. 

of  epiphysis  of  femur,  coxitis  delays,  594. 
Osteitis,  of  tibia  and  fibula,  radiograph  of,  560. 
tubercular,  594. 

X-ray  examinations  of  service  in,  556. 
Osteoarthropathy,  X-ray  examinations  of  service 

in  chronic  pulmonary,  556. 
Osteochondroma,  X-ray  examinations  of  service 

in,  556. 
Osteoma,  X-ray  examinations  of  service  in,  556. 
Osteomyelitis,  radiographs  of,  561,  563,  565-574. 
of  tibia,  case  of,  562. 

X-ray  examinations  of  service  in,  556,  722. 
Osteosarcoma,  332,  556. 

of  humerus,  radiograph  of,  579. 
Osteosclerosis,  use  of  X-rays  in,  596, 
Oudin,  on  use  of  X-rays  in  — 
acromegalia,  578. 
Pott's  disease,  596. 
tuberculosis  of  bones,  592,  594. 
Ovary,  case  of  cancer  of,  at  Boston  City  Hospital, 

442. 
Overwork,  as  cause  of  enlarged  heart,  271. 

lessens  power   of  resistance  to   tuberculosis, 

159- 
relaxation  of  cardiac  walls  from,  270. 
Oxalic  acid,  radiograph  of,  5. 
Oxygen,  atomic  weight  of,  3. 


Page  induction  coil,  8,  22-23. 
Pakhitonov,  Dr.,  report  of,  on  case  of  acne  vul- 
garis, 671. 
Palate,  case  of  cancer  of,  at  Boston  City  Hospital, 
442. 
lupus  of  hard,  420. 

motions  made  by  soft,  in  speaking,  389. 
Palmitic  acid,  radiograph  of,  5. 
Palpation    may  supplement   X-ray  examination, 

191. 
Pancreas,  abnormal  conditions  about,  detected, 

358. 
Paper,  for  printing  X-ray  negatives,  57,  554. 

transparent  to  X-rays,  2. 
Papilloma  of  larynx,  700. 
Paralysis,  of  laryngeal  nerve,  323. 

of  vocal  cord,  313,  315,  316. 
Patella,  radiographs  of  fracture  of,  499,  500,  501. 
Pathological   conditions    indicated   by   width   of 

heart,  261. 
Patient,  data  concerning,  81. 

position  of,  in  X-ray  examinations,  65-74.    See 

jutder  Position, 
precautions    relating   to,  in  using  X-rays  for 

diagnosis,  58. 
for  treatment,  446,  655. 
support  of,  during  X-ray  examination,  59. 
Pelvis,  378-383. 

Bouchacourt  on  deformity  of  the,  378-379. 
case  of  cancer  of,  at  Boston  City  Hospital,  442. 


Pelvis  {continued)  — 

fracture  of,  at  Boston  City  Hospital,  456. 
radiograph  ot  whistle  in,  551. 
Pemphigus  foliaceus,  treatment  of,  by  X-rays,  672. 
Pencil,  radiographic,  77-79. 
Penetration,  of  cloth  by  rays,  59. 

of  X-rays,  property  of,  2. 
Penis,  cases  of  cancer  and  of  carcinoma  of,  at 

Boston  City  Hospital,  442. 
Percussion,   and   X-ray    determinations   of    left 
heart  border,  table  of,  276-279. 
thickness  of  chest  wall  may  mislead  in,  198, 

282. 
compared  with  X-rav  examinations  in  cases 
of— 

aneurism,  312-313,  322-324. 

carcinoma  of  liver,  376-377. 

chlorosis,  297. 

displacement  of  heart,  295-296. 

fluid  in  chest,  213. 

heart  diseases,  162,  266-267,  269,  272- 

275.  295-296. 
lung  diseases,  162. 
pneumonia,  165-166,  183. 
tumors,  339-340. 
for  chest  examination,  109. 
emphysema  a  hindrance  to,  198. 
X-rays  give  more  definite  signs  than,  149. 
X-ray  examination  should  be  taught  in  con- 
nection with,  355. 
Pericardial    adhesions,    as    cause    of    enlarged 
heart,  271. 
displacement  of  heart  by,  293-294.     See  Ad- 
hesions. 
Pericardial  effusion,  300. 
Pericarditis,  position  for  examining  patient  with, 

300.  ^ 

Pericardium,  effect  of  stretching,  on  heart  pulsa- 
tions, 252. 
tapping,  in  case  of  effusion,  300. 
Perineum,  case  of  cancer  of,  at  Boston  City  Hos- 
pital, 442. 
Periostitis,  of  fibula,  radiographs  of,  558,  559. 
of  radius,  radiograph  of,  557. 
X-ray  examinations  of  service  in,  556. 
Peristaltic  movements  in   frogs,  dogs,  and  men 

observed,  372. 
Peritonitis,     chronic     tuberculous,     treated     by 

X-rays,  715. 
Pfahler,  Dr.  G.   E.,  report  by,  of  localization  of 

tumors  of  brain  by  X-rays,  645-646. 
Phalanges,  fractures  of,  467,  491-492. 
photographing  the,  522. 
radiograph  showing   loss  of  bone   substance 

in.  559- 
tuberculosis  of,  592. 

Phalanx,  radiograph  of  fracture  of,  493. 

Phantom  tumors,  377. 

Pharynx,  case  of  cancer  of,  at  Boston  City  Hos- 
pital, 442. 


INDEX 


749 


Philip,  Dr.  J.   H.,   on  use  of  X-rays    in    frontal 

sinus,  647. 
Phosphate  of  calcium,  radiograph  of,  5. 
Phosphate  of  sodium,  radiograph  of,  5. 
Phosphorus,  atomic  weight  of,  3. 
Photographs,   comparison    of  X-ray,  and  nega- 
tives, 96. 
comparison    of  X-ray,    and  screen  examina- 
tions, 99,  120,  169-171,  205,  270. 
development  of  X-ray,  57. 
of  heart,  best  made  during  deep  inspiration, 

270. 
importance    of    interpretation    of   X-ray,    in 

aneurism,  328. 
interpretation  of  X-ray,  in  surgery,  455. 
See  Negative,  Radiographs,  Views. 
Photographs  of — 

aneurism,  X-ray  outlines  of,  on  chest,  314. 
cancer  of  breast  before  treatment,  707. 
carcinoma  before  treatment,  701. 
carcinoma  of  breast  before  treatment,  703,705. 
carcinoma  of  breast  during  treatment  by  the 

X-rays,  704,  706. 
carcinoma  of  neck  before  treatment,  701. 
case  of  dextrocardia,  650. 
diaphragm,  normal  outlines  of,  on  chest,  107. 
epidermoid  cancer  of  eyelid  before  treatment, 

426,  684. 

epidermoid  cancer  of  eyelid  during  treatment, 

427,  684. 

epidermoid  cancer  of  lower  lid  before  treat- 
ment, 684. 

epidermoid  cancer  of  lip  before  treatment, 
422-423. 

epidermoid  cancer  of  lip  after  treatment,  424- 

425- 
epidermoid  cancer  of  hand  before  treatment, 

432-433- 

epidermoid  cancer  of  hand  after  partial  treat- 
ment, 435. 

epidermoid  cancer  of  hand,  section  of,  before 
treatment,  434. 

epidermoid  cancer  of  hand,  section  of,  after 
partial  treatment,  436-437. 

epidermoid  carcinoma  of  temple  before  treat- 
ment, 685. 

epidermoid  carcinoma  of  temple  after  treat- 
ment, 685. 

epithelioma  of  cheek  after  two  exposures  to 
the  X-rays,  68g. 

epithelioma  of  cheek  after  treatment,  690. 

epithelioma  of  lid  before  treatment,  686,  687. 

epithelioma  of  lid  after  treatment,  686,  687. 

epithelioma  of  lip  before  treatment,  428-429. 

epithelioma  of  lip  after  six  weeks'  treatment, 

430- 
epithelioma  of  lip  a  month  later  still,  431. 
epithelioma  of  nose  before  treatment,  685. 
epithelioma  of  nose  after  treatment,  686. 
epithelioma  of  orbit  before  treatment,  693. 


Photographs  of  (con/inued)  — - 

epitiielioma  of  orbit  after  treatment,  694. 

lupus  of  cheek  before  treatment,  402. 

lupus  of  cheek  after  treatment,  403. 

lupus  of  face  before  treatment,  404. 

lupus  of  face  after  partial  treatment,  405. 

lymphosarcoma    and    round-celled   sarcoma 
before  treatment,  698. 

lymphosarcoma    and    round-celled   sarcoma 
after  treatment,  699. 

method  of  applying  treatment,  400. 

psoriasis   after   partial   treatment   by   X-ravs, 
667. 

rodent  ulcer  of  face  before  treatment,  439. 

rodent  ulcer  of  face  after  treatment,  440. 

rodent  ulcer  of  nose  before  treatment,  688. 

rodent  ulcer  of  nose  after  treatment,  688. 

spindle-celled  sarcoma   before   treatment   by 
X-rays,  691. 

spindle-celled  sarcoma  after  treatment,  692. 
Photography,  dental,  603-614. 
Phthisis,  diagnosis  of,  not  made  by  X-rays  only, 
122-123. 

negative   results  in  therapeutic  treatment  of, 
418. 
Physicians,  need  of  X-ray  apparatus  by,  355-356. 

use  of  X-ravs  must  be  bv  trained,  355,  657- 
658. 
Physiology,  of  digestion,  372. 

of  voice  and  speech,  389. 
Picard,  work  bv,  on  X-ray  treatment  of  fractures, 

468. 
Pigment  in   skin,   a  hindrance   in   treatment   of 

lupus,  407. 
Pinaud,  X-ray  study  of  gravid  uterus  by,  382,  383. 
Pins,  experiment  in  photographing,  64,  65,  67. 
Plante  rheostatic  machine,  8. 
Plaster,  opacity  of,  to  X-rays,  471-473. 
Plaster-of-paris  bandage,  radiograph  of,  472. 
Plates,  photographic,  56-57. 

identification  of  position  of  87. 

support  of,  by  diaphragm,  95-96. 
Plates  for  static  machine,  10,  637. 

cleaning,  15,  637. 

method  of  holding,  10-13. 

removal  of  dampness  from,  14. 

speed  of,  14. 
Platino-cyanide  of  barium,  56. 
Pleurae,  adhesion  of  surfaces  of  the,  229-233. 

clearness  in,  necessary  to  deteriuine  borders 
of  heart,  247. 
Pleural  cavity,  fluid  and  gas  in,  285. 
Pleural   sac,  fluid   in,  in  empyeina  detected  by 

X-ray  examination,  192. 
Pleurisy,  diaphragmatic,  218. 

may  disguise  signs  of  tuberculosis,  124. 

displacement  of  heart  caused  by,  291. 

encysted,  216-217. 
Pleurisy  with  effusion,  202-233,  648-649. 

and  emphysema,  195,  218. 


750 


INDEX 


Pleurisy  {continued)  — 

new  growth  in  lung  suggested  by,  332,  340- 

341- 

and  pneumonia,  218-221. 

or  pneumonia,  186-191. 

and  pulmonary  tuberculosis,  222-229. 

relief  by  drawing  iluid  in  cases  of,  237. 

suggested  by  darkened  lower  lung,  353. 

tuberculosis  associated  with,  140,  142-143. 
Pleuritic  adhesions,  229-233. 

expansion  of  lungs  lessened  by,  167. 

excursion  of  diaphragm  limited  by,  180. 

"stitch"  in  side  associated  with,  233. 
Pleuritic  effusion,  effect  on  position  of  heart  of, 
285. 

an  obstruction  to  viewing  heart,  247. 
Pleuritic  fluid,  experiments  with,  6. 
Plumb-lines,  60,  66. 

indirect,  66,  69,  70. 
Pneumohydrothorax,  70-71,  213,  241,  647-648. 
Pneumonia,  103,  164-192. 

appendicitis  confounded  with,  192. 

colds  bordering  on,  192. 

darkened  middle  of  lung  suggests,  353. 

empyema  overlooked  after,  192. 

influenza  accompanied  by,  191-192. 

interstitial    fibrous,   resemblance   of,   to   new 
growth,  343-344- 

new  growth  in  lung  suggested  by,  332. 

in  old  people,  185. 

outline  on  fluorescent  screen,  173. 

pleurisy  with  effusion  and,  218-221. 

pleurisy  or,  186-191. 

and  tuberculosis,  124. 

or  tuberculosis,  191. 
Pneumopyothorax,  70-71,  241. 
Pneumothorax,  234. 

Poland,  on  epiphyseal  lesions  in  children,  461. 
Polarization,  property  of,  claimed  for  X-rays,  i. 
Position,  of  foreign  object  in  body,  locating,  81- 
86. 

of  heart  (normal),  247. 

of  heart  in  women,  260. 

of  needle  in  hand,  change  of,  545-546. 

of  patient  in  examination  for  heart  diseases, 
247,  258,  263. 

of  patient  in  examination  of  pericarditis,  300. 

of  patient  in  examination  of  pleurisy,  205. 

of  patient  in  examination  of  pneumohydro- 
thorax, 70-71,  241,  244. 

of  patient  in  photographing  fracture,  473. 

of  patient  in  photographing  pelvis,  379. 

of  patient  in  photographing  sacrum,  379. 

of  patient  in  X-ray  examination.  59-74. 

of  plates  in  examining  patient,  88-97. 

of  plate,  identification  of,  87. 

of  plate,  patient,  and  tube,  necessity  of  know- 
ing, 66,  67,  89. 

of  plate,  in  photographing  bones  of  face,  475. 

of  plate,  in  photographing  spine,  475. 


Position  (continued)  — 

of  plate,  in  photographing  teeth,  606. 

of  roots  of  teeth,  611. 

of  stomach  during  digestion,  362-372. 

of  vacuum  tube  and  plate,  64-65,  674. 
Potassium,  atomic  weight  of,  3. 

chloride  of,  radiograph  of,  5. 
Pott's  disease,  X-rays  of  value  in  showing  extent 

of,  596. 
Pregnancy,  extra-uterine,  X-rays  confirm  diagno- 
sis of,  382. 
Price,  Dr.  Weston  A.,  radiographs  of  teeth  by, 

608,  609,  610,  612,  614. 
Process,  of  digestion,  observing,  362-373,  651-653. 

of  healing  in  lupus  cases,  395-396. 

of  ossification,  462,  594. 
Processes,  acute  and  chronic,  compared,  354. 
"  Progression  in  teeth,"  608. 
Prostate,  cases  of  cancer  and  of  carcinoma  of, 

at  Boston  City  Hospital,  442. 
Prurigo,  X-ray  treatment  of,  672. 
Pruritus  ani  and  vulva;.  X-ray  treatment  of,  674. 
Psoriasis,  418,  666-669. 

Psoriasis  vulgaris.  X-ray  treatment  for,  411-412. 
Pulmonary  area,  method  of  determining  whether 

of  normal  brightness,  102. 
Pulmonary  tuberculosis,  111-163. 

absence  of  result  in  exposing  patient  with,  to 
X-rays,  418.     Result,  715. 

aneurism  suggesting,  313. 

most  widespread  of  all  diseases,  159. 

pleurisy  with  effusion  and,  222-229. 

See  Tuberculosis. 
Pulsation,  lack  of,  in  aneurism,  310. 
Pulsations  of  heart,  249,  252. 

blur  outlines  of  X-ray  photographs,  270. 

in  cardiac  disease,  299. 
Pulse,  state  of,  after  exercise,  390. 
Pus,  cup  full  of,  under  fluorescent  screen,  205. 

and  water,  experiment  with,  6. 
Pusey,  Dr.  William  Allen,  on   case  of  sarcoma 
treated  by  X-rays,  695-696. 

on  X-rav  treatment  of  Hodgkin's  disease,  717- 
718.' 
Pyelitis,  623. 
Pylorus,  cancer  of,  377. 

R 

Rabbits  inoculated  with  bacteria,  effect  of  X-rays 
on,  452. 

Radiographs,  comparative  merits  of,  and  screen 
examinations.     See  Fluorescent  screen  ex- 
aminations, 
better  adapted  to  surgeon  than  to  physician, 

455' 
Forster  and  Hugi's  experiments  with,  546,  550. 
fractures  recognized  by,  469,  470. 
importance  of,  in  fractures  and  dislocations, 

468-469. 
light  required  for  taking,  47. 


INDEX 


751 


Radiographs  (continued^  — 

localization  of  fort-ign  bodies  by,  533-538. 

medico-legal  uses  of,  634. 

precautions  necessary  in  taking,  86-87. 
Radiographs  ot  — 

abscess,  573,  574. 

aluminum,  472. 

aorta,  250. 

arthritis  of  finger-joints,  597. 

blood,  vulcanite  cup  containing,  7. 

calcified  tissues,  386,  387. 

calculi,  616,  618,  619,  620. 

calluses,  485,  516. 

chondrosarcoma  of  femur,  581. 

clavicles  and  ribs,  104. 

constituents  of  the  body,  5. 

cotton,  472. 

coxa  vara,  577. 

decalcified  bones,  616. 

dextrocardia,  650. 

disease  of  bones  and  joint,  595. 

dislocation  of  both  bones  of  forearm,  527. 

dislocation  and  separation  of  epiphysis,  528, 

529- 
emphysema,  199. 
exostosis,  586. 

exostosis  of  ulna  and  radius,  588,  589. 
finger,  582,  583. 
fiat  foot,  601. 
foot,  523,  524. 

foreign  bodies  in  oesophagus,  540,  541. 
fractures  of  both  bones  of  leg,  470,  505,  506, 

509,  516,  517,  518,  519. 
fracture  of  epiphysis,  521. 
fractures  of  femurs,  497,  498. 
fractures  of  fibula,  504,  507,  508,  511,  520,  560. 
fracture  of  fifth  metacarpal  bone,  495. 
fracture  of  fouith  metacarpal  bone,  494. 
fractures  of  humerus,  476,  477,  478,  479. 
fractures  of  olecranon,  479,  480. 
fracture  of  patella,  499,  500,  501. 
fracture  of  phalanx,  493. 
fractures  of  radius,  483,  484,  486,  487,488,490, 

491. 
fracture  of  third  metacarpal  bone,  492. 
fracture  of  thumb,  496. 

fractures  of  tibia,  502,  503,  510,  511,  514,  520. 
fracture  of  toes,  525. 
fracture  due  to  torsion,  518. 
fracture  of  ulna,  481. 
gall  stones,  616. 
glass  in  finger,  550. 
heart,  250,  251. 
hyoid  bone,  88. 
iodoform  bandage,  472. 
kidney,  620. 

loose  cartilage  in  knee-joint,  599. 
lung,  tuberculous,  112. 
malformation  of  hand,  463,  464. 
mill  board,  472. 


Radiographs  of  [coiifi/nwd)  — 
necrosis  of  lower  jaw,  561. 
needle  in  hand,  545,  546,  547. 
needle  in  os  calcis,  544. 
needle  in  wrist,  548,  549. 

needles  threaded  with  catgut,  horsehair,  iron- 
dyed  silk,  silkworm  gut,  and  silk,  472. 
new  growth  in  lung,  337. 
osteitis  of  tibia  and  fiijula,  560. 
osteo-arthritis  of  great  toe-joint,  600. 
osteomyelitis,  561,  565-573. 
osteosarcoma  of  humerus,  579. 
pelvis,  380,  381. 
periostitis  of  fibula,  558. 
periostitis  of  radius,  557. 
phalanges,  showing  loss  of  bone  substance  in, 

559- 
pins,  65,  67. 

plaster-of-paris  bandage,  472. 
rickets,  576. 

rubber  drainage  tube,  472. 
rubber  plaster,  472. 
separation   of  epiphysis  of  tibia  and  fibrous 

fracture  of  fibula,  507,  508. 
shot  in  foot,  552. 
silver  wire,  472. 
split  in  fibula,  510. 
staphylococcus  infection,  582,  583. 
steel  in  arm,  542,  543. 
subdislocation  of  metatarsus,  530. 
teeth,  608,  609,  610,  611,  612,  613. 
thickened  tibia,  573,  574. 
tin,  472. 
trachea,  88. 

tuberculosis  of  ankle,  590. 
tuberculosis  of  bones  (probable),  595. 
tuberculosis  of  foot,  591,  592. 
tuberculosis  of  hip,  593. 
tuberculous  lung,  112. 
tumor  of  finger,  585. 
ununited  fracture  and  necrosis,  482. 
vertebrte,  cervical,  90,  91. 
vesical  calculus,  618. 
water,  vulcanite  cup  containing,  7. 
whistle  in  oesophagus,  541. 
whistle  in  pelvis,  551. 
wooden  splint,  472. 
Radius,  exostosis  of,  radiographs  of,  588,  599. 
fracture  of  left,  488-490. 
fractures  of,  radiographs  of,  484,  486-488,  490, 

491. 
method  of  photographing  fracture  of,  488. 
osteomyelitis  of,  radiograph  of,  571,  572. 
periostitis  of,  radiograph  of,  557. 
Reco.ds,  of   appearances    seen    on    fluorescent 

screen,  77,  99. 
of  position  of  tube  with  reference  to  plate,  473. 
of  X-ray  examinations  of  chest,  no. 
Recoveries  from  tuberculosis,  percentage  of,  160, 

161. 


752 


INDEX 


Rectum,  cases  of  cancer  and  of  carcinoma  of,  at 
Boston  City  Hospital,  442. 
treatment  of  cancerous  stricture  of,  700,  712. 
Recurrence  of  lupus,  397-398. 
Redard,  on  value  of  X-rays  in  coxitis,  594. 
Rc-fraction,  property  of,  claimed  for  X-rays,  i. 
Regeneration  of  bones  after  operation,  562. 
Regulator,  automatic,  639-640. 
Regurgitatif  n  of  the  blood,  effect  on  heart  pulsa- 
tions, 300. 
Remy,  report  by,  on   radiographs   of  muscles  of 

animals,  466. 
Renal  disease  inferred  from,  enlarged  heart,  283. 

appearances  in  lungs,  307,  354. 
Renal  diseases,  374-375.      See  Bladder,  Kidneys, 
Ureters, 
value  of  X-ray  e.xaminations  in,  306. 
Resistance  of  vacuum  tubes,  42-43,  47-48. 

methods  of  changing,  44,  45. 
Respiration,  in  emphysema  of  the  lungs,  193,  194. 
excursion  of  diaphragm  in  normal,  108. 
experiment  showing  effect  of,  on  appearance 

of  lungs  on  screen,  100. 
of  fcEtus,  determination  of,  383. 
movement  of  stomach  during,  362-364. 
m  pleurisy  with  effusion,  203-204. 
in  X-ray  examinations  for  tuberculosis,  118. 
Rheostat,  22. 

Rheumatism,  acute  articular,  127-129,  289. 
articular,  treated  by  X-rays,  445-446. 
association  of  tuberculosis  and,  130. 
of  joints.  X-ray   examinations  of  service   in 
556. 
Ribs,  appearance  of,  on  fluorescent  screen,  100, 
102,  103;  in  emphysema,  193. 
fractures  of,  at  Boston  City  Hospital,  456. 
radiograph  of,  104. 
Rickets  575. 

radiograph  of  case  of,  576. 
use  of  X-rays  in  recognition  of,  385. 
X-ray  examinations  of  service  in,  556. 
Rieder,  reports  by,  on  experiments  with  bacteria 
exposed  to  X-rays,  449,  450-451,  452. 
use  of  intensifying  screen  by,  639. 
X-ray  study  of  diseases  of  chest  by,  120,  356, 
418. 
Ringel,  on  comparative   permeability  of  calculi 
by  X-rays,  617. 
on  photographing  the  hand,  93. 
Ritchie  coil,  19,  23,  24,  25,  638. 
Riviere,  experiments  of,  with  bacteria  and  X-rays, 

449-450. 
Rodent  ulcers.     See  Ulcer. 
Roentgen,  i,  2,  34. 

Rollins,  Dr.  William,  experiment  of,  with  so-called 
X-ray  burn,  448. 
experiments  by,  with  guinea  pigs,  to  determine 

effect  of  X-rays  on  cell  growth,  710-711. 
invention  and  manipulation  of  X-ray  apparatus 
by,  17,  18,  27,  28-31,  32,  34,  35^  36,  37,  38, 


Rollins,  Dr.  William  {continued)  — 

42,  44.  46,  50.  52.  54.  60,  262,  400,  475,  604, 

606,  607,  608,  613,  621-622,  641,  642,  655. 
value  of  work  of,  614. 
Ross,  Dr.,  on  value  of  X-rays  in  cases  of  fracture, 

467-468. 
Ross,  Forbes,  experiments  of,  with  bacteria  and 

X-rays,  449. 
Roux,  observation  of  process  of  digestion  by,  372. 
Rowland,  arrangement  of  vacuum  tube  by,  35. 
Rowland,  Sidney,  report  of,  on  case  of  osseous 

ankylosis,  598-602. 
Rubber  plaster,  radiograph  of,  472. 
Ruhmkorff  induction  coil,  8,  22-25. 

S 
Sabrazes,    experiments    of,    with    bacteria    and 

X-rays,  449-450- 
Sacrum,  position  of  patient  in  photographing,  379. 
Salve,  carbolanolin,   use    of,  after  treatment   for 
favus,  416. 
Unna's,  in  combination  with  X-rays,  396. 
Sarcoma,  578,  581,  695-696. 

spindle-celled,  343,  691-692. 
Saw,  fracture  of  ulna  caused  by,  481. 
Sayen's  vacuum  tube,  44. 

Scapula,  fractures  of,  at  Boston  City  Hospital,  456. 
Scar,  after  treatment  for  lupus,  395. 

after  treatment  for  naevus  flammeus,  413. 
Scar  tissue,  hyperlrophied,  treated  by  X-rays,  712. 
Scheffer,  W.,  457  n. 

Scheier,  Max,  investigations  of,  concerning  voice 
and  larynx,  389. 
study  of  ossification  of  cartilage  of  pharynx  by, 

462. 
use  of  X-rays  in  examination  of  frontal  cavities 
by,  464-465. 
Schenkel,  observations   by,  of  use   of  X-rays   in 

lupus,  396,  398. 
Schiff,  on  use  of  X-rays  in  acne,  418. 

on  use  of  X-rays  in  lupus,  391,  395,  398,  404- 

405- 
X-ray  treatment  of  sycosis  and  favus  by,  414- 
416. 
Schmid-Monnard,  445. 

Scholtz,  report  by,  on   treatment  of  leprosy   and 
mycosis  fungoides,  71.).. 
on  treatment  of  pruritus  vulvas,  674. 
Schorstein,  report  by,  of  case  of  congenital  mal- 
formation, 463. 
Schott,  T.,  photographs  by,  of  hearts  of  children, 

390. 
Schultz,    experiments    of,   with    color-producing 

bacteria  and  X-rays,  449. 
Screen,  aluminum,  47,  53-54,  655. 
platino-cyanide  of  barium,  56. 
tungstate  of  calcium,  55. 
Sec  Fluorescent  screen. 
Scrotum,  case  of  cancer  of,  at  Boston  City  Hospi- 
tal, 442. 


INDEX 


75. 


Sedeiholm,  on  X-ray  treatment  of — 
old  ulcerations,  716. 
pruritus  ani  and  vulvct,  674. 
warts,  672. 
Seehear,  60,  262. 

Seidlitz  powder,  use  of,  in  observing  stomach,  359. 
Sequeira,  James   H.,  on  case  of  leprosy  treated 
by  X-rays,  714. 
on   X-ray  treatment  of  rodent  ulcer,  438-439, 
692-693. 
Serous  fluid  and  pus  compared,  205. 
Shadow,  X-ray  picture  a,  62. 

Shadow  on  fluorescent  screen,  of  abnormal  heart, 
262. 
of  abnormal  portions  of  lungs,  103. 
in  aneurism,  310. 
of  apices  of  lungs,  118-119. 
of  blood  vessels  and  soft  tissues  in  heart  exam- 
inations, 262. 
in  cases  of  broncho-pneumonia,  192. 
of  calcification  of  ascending  aorta,  385. 
of  foreign  bodies,  531-532. 
of  foreign  substance  in  body,  81-85. 
of  hypertrophied  bronchial  glands,  119. 
of  interlobar  fluid,  218. 
of  lung  in  pneumonia,  164. 
of  lung  in  pulmonary  tuberculosis,  iii. 
of  metal  pencil-holder,  77. 
of  new  growth  in  lung,  332. 
of  pericardial  effusion,  300. 
in  pulmonary  congestion,  158,  201. 
of  pus,  205. 
of  serous  fluid,  205. 
of  spleen,  373-374- 
of  sticking  plaster,  86. 
Shadows,  character  of  X-ray,  1-2. 
Shield  for  patient  in  X-ray  treatment,  399-401, 

425,  446,  655,  657,  675. 
Shingles  treated  by  X-rays,  666. 
Shot  in  foot,  radiograph  of,  552. 
Shoulder,  cases  of  cancer  of,  at  Boston  City  Hos- 
pital, 442. 
photographing  the,  89,  640. 
X-ray  photographs  in  fracture  of,  481-485. 
Shoulder  joint,  radiographs  of,  457. 
Side,  case  of  cancer  in,  at  Boston  City  Hospital, 
442. 
"  stitch  "  in,  233. 
Sigmoid  flexure,  method  of  following  outline  of, 

358. 
Silk,  radiograph  of  needle  threaded  with,  472. 
Silkworm   gut.   radiograph    of  needle    threaded 

with,  472. 
Sinapius  on  treatment  of  pulmonary  tuberculosis 

by  X-rays,  418. 
Sinus,  radiograph  of,  573-574- 
recognizing,  by  X-rays,  458. 
size  of,  recognized  by  X-rays,  241. 
Sinuses,  frontal,  647. 
tuberculous,  715-716. 


Siphon  for  withdrawing  air  in  pneumothorax,  238. 
Sittings,  length  and  frequency  of,  in  lupus,  401- 

403- 
Sjogren,  case  of  rodent  ulcer  reported  by,  438. 
on  X-ray  treatment  of — 
old  ulcerations,  716. 
pruritus  ani  and  vulvae,  674. 
warts,  672. 
Skeleton,  development  of  the,  459-462. 
Skiagrams  for  localizing  foreign  body  in  eye,  536- 

.       537- 
Skin,  affections  relieved  by  exposure  to-  X-rays, 
391,  664-674. 
cancer.     See  Ulcer,  rodent, 
changes  produced  in,  by  different  exposures, 

447- 
diseases.     Sec  Acne,  Eczema,  Psoriasis, 
effect  of  X-rays  on,  416,  658-660. 
normal  and  abnormal,  392. 
susceptibility  of,  diminished  by  dermatitis,  396. 
tracings  on.     See  Skin-tracings. 
Skinner,  Dr.,  report  by,  on  cases  of  cancer,  711- 

712. 
Skin-tracings,  77-80. 

in  heart  examination,  248,  264. 
iodine  for  removing,  532. 
in  observations  of  stomach,  360. 
Skull,  fractures  of,  456,  475. 
Smith,  A.  Everett,  report  by,  of  X-ray  treatment 

of  lupus  vulgaris,  397. 
Smith,  Xoble,  on  use  of  X-ray  photography  in 
cases  of  injured  spine,  475,  479,  481,  522, 
594-596. 
Sodium,  atomic  weight  of,  3. 

radiographs  of,  5. 
Sokolow  on  X-ray  treatment  of  articular  rheuma- 
tism in  children,  445-446. 
Spark-gap,  adjustable,  15,  16. 

adjustable  multiple,  16,  17,  26,  27,47,  48.  636. 
Specialists,  X-ray  examinations  preferably  by,  355. 
Speculum ,  glass,  for  treating  cancer  of  tongue,  676. 
Speech,  physiology  of,  389. 
Speed  controller,  14,  93. 
Speed  of  plates,  14,  637. 
Spiess  on  use  of  X-rays  in  examination  of  frontal 

cavities,  465. 
Spina  bifida,  464. 
Spinal  column,  examination  of,  310-311. 

tuberculous  foci  on,  594. 
Spina  ventosa,  562. 
Spine,  caries  of,  594,  596. 

case  of  cancer  of,  at  Boston  City  Hospital,  442. 
fractures  of,  at  Boston  City  Hospital.  456. 
photographing  the,  88,  94-97,  475-481. 
position  of  plate  and  tube  in  examining,  88. 
Spleen,  observations  of,  by  X-rays,  358,  373-374. 
Splints,  advantage  of  wooden,  in   taking  radio- 
graphs. 86,  471,  473. 
radiograph  of  wooden,  472. 
Spottiswoode  electrolytic  break,  20. 


754 


INDEX 


Sprains,  aid  of  X-rays  in  examining,  467. 
Stamm,  use  of  X-rays  by,  in   case  of  syphilitic 

disease,  596. 
Staphylococcus  pyogenes,  results  of  X-ray  experi- 
ments with,  450. 
Starch  bandage,  radiograph  of,  472. 
Startin,  Dr.  James,  report  of,  concerning  case  of 
lupus  erythematosus,  714. 

on  X-ray  treatment  of  psoriasis,  668. 
Static  machine,  8-19,  636-637. 

compared  with  coils,  638-639. 

location  of,  15. 

for  use  in  the  country,  31-32. 

See  Apparatus. 
"  Stave  of  the  thumb  "  fracture,  492. 
Stearic  acid,  radiograph  of,  5. 
Steel,  localization  of  piece  of,  540. 
Stenbeck,  on  X-ray  treatment  of  articular  rheuma- 
tism, 446. 

on  X-ray  treatment  of  rodent  ulcer,  437-438. 
Stereoscope,  use  of,  in  examining  fractures,  457, 
469-471. 

use  of,  in  interpreting  elbow  fractures,  485-487. 
Sternum,  fractures  of,  at  Boston  City  Hospital,  456. 
Sticking  plaster,  shadow  cast  by,  86. 
Siine,  \V.  M.,  on  so-called  X-ray  burn,  447. 
"  Stitch "    in   side   associated  with   pleuritic   ad- 
hesions, 233. 
Stokes,  G.  G.,  i. 
Stomach,  carcinoma  of  the,  376,  421. 

cases  of  cancer  and  of  carcinoma  of,  at  Boston 
City  Hospital,  442. 

device  for  withdrawing  foreign  bodies  from, 
720-721. 

length  of  stay  of  food  in,  372-373. 

methods  for  observing  the,  359,  651-653. 

movement  of,  during  respiration,  362-363. 
Stomachs,  observations  of  cats',  360,  372,  651-653. 

observations  of  children's,  360-372. 

observations  of  dogs',  372. 

observations  of  frogs',  372. 
Stones  in  bladder  and  kidneys,  623-629. 
Stretchers,  59,  60,  6r,  63,  76,  78,  92,  94,  95,  97,  656. 
Stricture,  oesophageal,  313,  323-324,  357. 
Subnitrate  of  bismuth  injected  in  empyema,  241. 
Subnitrate,  emulsion  of,  used  for  observing  stom- 
ach, 359. 
Sulphate  of  sodium,  radiograph  of,  5. 
Sulphur,  atomic  weight  of,  3. 

baths  in  combination  with  X-ray  treatment  for 
eczema,  409. 

radiograph  of,  5. 
Sunlight,  concentrated,  for  treating  lupus,  407. 
Surgery,  introduction  to,  454-458. 

dental,  603-614. 

military,  553-555. 
Swain,  Dr.,  recognition  of  calculus  bv  X-ravs,  623. 
Sweet,  Dr.  William  M.,  apparatus  of,  for  treat- 
ment of  injuries  to  the  eye,  537-538,  719. 

on  action  of  X-rays  on  nerve  structures,  664. 


Swelling,  of  foot.  X-rays  show  cause  of,  522. 

about  Iractuies,  458. 

of  joints,  458. 
Sycosis,  Freund  and  Schiff's  treatment  of,  414, 
415,  416. 

non-parasitaria,  416. 
Symons,  on  use  of  X-rays  in  military  surgery,  553. 
Synostosis,  462. 

Syphilis,  353,  406-407,  556,  596-597. 
Systole,  form  of  heart  in,  253-257. 


Table,  of  atomic  weights  of  elements  of  human 

body,  3. 
of  cases  of  cancer  of  breast  treated  by  X-rays, 

702. 
of  cases   of   cancers    and   of   carcinomas   at 

Boston  City  Hospital  for  a  series  of  years, 

442. 
of  cases  of  fractures  treated  in  Boston  City 

Hospital  for  fifteen  years,  456. 
of  cases   of  larger   new   growths   treated   by 

X-rays,  697. 
of  cases  of  new  gro\\ths  treated  by  X-rays  prior 

to  1903,  678-682. 
of  smaller  new  growths  treated  by  X-rays,  683. 
of  diseases  of  bones  and  joints  in  which  X-ray 

examinations  are  of  service,  556. 
of  elements  of  bones  of  healthy  child  and  of 

rachitic  bones,  575. 
of  heart  weights  compared  with  heart  widths, 

273- 
of  skin   diseases  treated   at  the    Boston  City 

Hospital  during  a  recent  year,  665. 
of  times  of  exposure  for  taking  X-ray  photo- 
graphs, 640. 
showing    advantages   and    disadvantages    of 

static  machine  and  coil,  638. 
showing  difference  of  X-ray  and   percussion 
determinations    of    left   heart    border,    on 
level  with  nipple,  during  expiration  in  155 
cases,  276-279. 
showing  width  of  heart  in  relation  to  height 
of  individual,  261. 
Tachycardia,  mobility  of  heart  in  paroxysmal,  301. 
Tapping.     See  Pleurisy  and  Pneumothorax. 
Target  of  vacuum  tubes,  32,  65-66. 
faulty  position  of,  37. 
position  of,  in  heart  examination,  247. 
position  of,  to  object  examined,  65,  87. 
united  with  anode,  35-36. 
Taylor,  Dr.,  recognition  of  calculus   by  X-rays, 

623. 
Taylor,  Dr.  George  G.  Stopford,  on  X-ray  treat- 
ment of  old  ulcerations,  716-717. 
Teeth,  603-614. 

progression  in,  608. 
radiographs  of,  608-613. 
unerupted,  607. 
Teleangiectasia,  congenital,  412-413. 


INDEX 


755 


Tesla,  screen  for  shielding  patient  recommended 
by.  47.  58,  91- 

on  so-called  X-ray  burn,  448. 
Tesla  induction  coil,  8. 

Testicle,  cases  of  cancer  of,  at  Boston  City  Hos- 
pital, 442. 
Therapeutic  uses  of  X-rays,  391-453,  654-719. 
Ihigh,   method   of  photographing   fractures   of, 
495-496. 

time  of  exposure  for  photographing  the,  640. 

tumor  of  the,  582-583. 
Thomson,  Elihu,  447-448,  457. 
Thomson  coil,  8. 

Thomson's  dynamo  static  machine,  8,  19. 
Thorax,  loo-iio,  647-651. 

abnormal  condition  of,    in  pleuritic  effusion, 
205. 

abnormal  condition  of,  in  empyema,  205. 

aneurism  of,  new  growth  may  simulate,  332. 

case  of  cancer  in,  at  Boston  City  Hospital,  442. 

measuring  density  of,  105-106. 

method  of  examining,  illustration  showing,  76. 

new  growths  in,  332-352. 

screen  examination    of,  preferable   to   photo- 
graph, 99. 
Throat,  cases  of  carcinoma  of,  at  Boston  City 

Hospital,  442. 
Thumb,   fractures   of,    at  Boston  Citv  Hospital, 
456. 

dislocation  of,  radiograph  of,  526. 

fracture  of,  radiograph  of,  496. 
Thyne,  Dr.,  recognition  of  calculus  by  X-rays,  623. 
Thyroid  cartilage,  photographing  the,  89. 
Tibia,  fractures  of,  radiographs  of,  502,  503,  510- 
512,  514,  520. 

osteitis  of,  radiograph  of,  560. 

osteomyelitis  of,  562,  563,  565-570. 

thickened,  radiograph  of,  573,  574. 

thickening  of  the,  596. 
Time,  for  exposure  of  photographic  plates,  62-64, 
96-98,  606-607,  640. 

in  which  stomach  retains  food,  372-373. 

length   of,   necessary    to   arrest   Juberculosis, 
160-161. 
Tin,  radiograph  of,  472. 
Tissues,  calcification  of,  385-387. 
Toepler-Holtz  influence  machine,  8. 
Toes,  fractures  of,  456,  525. 

osteo-arthritis  of  joint  of  great,  598,  600. 
Tongue,  cases  of  cancer  and  of  carcinoma  of,  at 
Boston  City  Hospital,  442. 

new  growths  on,  700. 
Tonsil,  cases  of  cancer  and  of  carcinoma  of,  at 

Boston  City  Hospital,  442. 
Torsion,  radiograph  of  fracture  due  to,  518. 
Trachea,  cut  of,  88. 

obstruction  of,  by  new  growth,  200. 
Tracheotomy  to  remove  swallowed  nutshell,  201. 
Tracing  cloth,  79,  265. 
Tracings  on  skin.     See  Skin-tracings. 


Transparency  of  lungs  during  deep  inspiration, 

100,  248. 
Treatment,  too  early  cessation  of,  in  heart  dis- 
eases, 305. 
Trendelenburg  position  for  photographing  pelvis, 

379- 
Triangle-shaped  area  in  heart  examinations,  258, 

259.  300.  336. 
Trowbridge,  Professor  John,  39-40,  448,  457. 
Trowbridge's  directly  connected  system,  32. 
Tube  holder,  47-55,  604,  605,  655. 
Tubercle  bacilli,  in  sputa,  121. 
test  for,  121-122. 

X-ray  experiments  with,  450-451. 
Tuberculin,  121-122. 

Tuberculosis,   acute  miliary.  X-ray  examination 
valuable  in,  125,  157. 
of  ankle,  radiograph  of,  590. 
association  of,  and  acute  articular  rheumatism, 

130, 
association  of,  and  some  other  disease,  140. 
of  the  bones,  575. 
displacement  of  heart  in,  288. 
distinguishing,  from  pneumonia,  191. 
dyspepsia  a  symptom  of,  162. 
early  definition  of,  117. 
early  comparative  value  of  screen  and  X-ray 

photograph  in,  120. 
of  foot,  587. 

of  foot,  radiograph  of,  591,  592. 
of  hip,  radiograph  of,  593. 
incipient  pulmonary,  139-140. 
indicated  by  physical  signs  but  not  by  X-rays, 

143-147- 

laryngeal,  treatment  of,  418. 

of  phalanges,  592. 

physical  signs  of,  hidden  by  emphysema,  198. 

in  pleurisy  cases,  detected  by  screen  examina- 
tions, 222-229. 

pulmonary,  111-163,  715. 

pulmonary,  cases  where  X-ray  examination  is 
valuable,  124. 

pulmonary,  most  widespread  of  all  diseases, 

159- 
pulmonary,  suggested  by  darkened  apex  of 

lung,  353. 
suggested  by  cases  of  aneurism,  313. 
suggested  by  pneumohydrothorax,  241. 
X-ravs    reported     ineffective     in    therapeutic 

treatment  of  cases  of  pulmonary.  418. 
tumor  in  brain,  detection  of,  by  X-rays,  340, 

645-647- 
of  finger,  radiograph  of,  585. 
of  humerus,  use  of  X-rays  in  examining,  596. 
of  stomach,  treatment  of,  by  X-rays,  421. 
Tumors,  in  chest,  339-343- 

differentiation  of  bony,  frotn  others,  582-583. 
enlargement  of  heart  caused  by,  271. 
on  forearm.  X-ray  examination  of,  596. 
phantom,  377.     See  .\ew  growths. 


75^ 


INDEX 


Tungstate  of  calcium  screen,  55-56,  640-642.  ■ 
Turbert,  report  by,  on  use  ol  X-rays   in  gravid 

uterus,  382. 
Typhoid   bacillus,  X-ray  exjieriments  with,   448, 

451- 
Typhoid  fever,  caution  about  food  in,  288. 
new  growth  in  patient  with,  345. 

U 

Ulcer,  carcinomatous,  434-437. 

of  cornea,  719. 

rodent,  437-443.  691-695. 

syphilitic,  406,  407. 
Ulcerations   on  back  of  chest  healed  by  X-rays 
applied  to  front,  419-420. 

old,  716-717. 
Ulcers  produced  by  long  and  intense  exposure, 

447.  658-659. 
Ulna,  deficiency  of  shaft  of,  462. 

fracture  of,  481. 

method  of  photographing  fracture  of,  488. 

and  radius,  exostosis  of,  radiograph  of,  588, 

589- 
Unna,  on  changes  in  skin  from  exposure  to  ex- 
cited vacuum  tube,  447. 
Unna's  salve,  X-rays  in  combination  with,  396. 
Uranium,  atomic  weight  of  3. 
Ureters,  method  of  examination  for,  617. 
Uric  acid,  elements  of,  3-4. 

Uterus,  cases  of  cancer  and  of  carcinotna  of,  at 
Boston  City  Hospital,  442. 
cancer  of,  710. 
gravid,  382-383. 

V 

Vacuum  tube,  32,  34-41. 

distance  of,  from  patient,  for  therapeutic  pur- 
poses, 401,  656-657,  666,  670,  675. 

importance  of    resistance    of,   in    therapeutic 
uses,  393-394,  640,  655. 

separate  and  distinct  actions  of  radiation  from, 
420-421. 

shielding,  from  patient,  400-401,  655. 
Vacuum  tube  position,  in  examining  the  heart, 
247,  263. 

in  examinmg  joints,  587. 

for  examining  patient  in  pericarditis,  300. 

in  examining  stomachs  of  children,  360. 

in  photographing  foot,  522. 

in  photographing  pelvis,  379. 

in  photographing  shoulder  and  elbow,  481,  488. 

relative  to  plate,  62-65. 

relative  to  patient,  88. 

in  treating  eczema  of  legs,  407. 

in  treating  lupus,  391-392. 
Vagina,  case  of  cancer  of,  at  Boston  City  Hospi- 
tal, 442. 
Van  Ziemssen,  120,  356. 

use  of  intensifying  screen  bv,  639. 
Variation  in  appearance  on  screen  in  acute  and 
chronic  processes,  354. 


\'arnier,  X-rav  studv  of  gravid  uterus  bv,  382, 

383- 
\'aseline.  X-rays   in  combination  with,  396-397, 

409.  413- 
Velox  paper,  57,  457. 

Vena  cava,  superior.  X-ray  ])hotograph  of,  387. 
Ventricle,  left,  widening  of,  by  exercise,  390. 

right,  enlarged  in  emphysema,  193. 

right,  pulsations  of,  during  inspiration,  252. 
Ventricles,  appearance  of.  on  screen,  100. 
Verruca,  X-ray  treatment  of,  672. 
Vertebra;,  caries  of  cervical,  594,  596. 

cervical,  radiograph  of,  90,  91. 

examination  for  displacement  of,  310-311. 

photographing  the,  475. 

value  of  X-rays  in  diseases  of,  587. 
Vesalius,  opinion  of,  on  shape  of  heart  in  systole, 

254- 

Views,  importance  of  taking   two,   of  fractures, 
457.  469.  473.  485.  488,  495,  497,  499,  505- 
506,  510,  542-544,  634. 
interpretation  of.     Ser  under  Interpretation. 

Virchow,  account  by,  of  case  of  myositis  ossifi- 
cans, 465-466. 

Vocal  cord,  paralysis  of,  313,  315,  316,  347. 

Voice,  physiology  of  the,  389. 

\'on  W'olfenden,  experiments   of,   with    bacteria 
and  X-rays,  449. 

Voss  influence  machine,  8. 

Vowels,  shape  of  palate  in  pronouncing  the,  389. 

Vulva,  cases  of  cancer  of,  at  Boston  City  Hospi- 
tal, 442. 

^\• 

Wagner,   Dr.,  recognition  of  calculi  by  X-rays, 

625. 
Walker,  Dr.  Norman,  report  by,  on  treatment  of 

mycosis  fungoides,  714. 
Walsham,  Dr.,  X-ray  examination  by,  of  lungs 

of  foetus,  383. 
War,  use  of  X-rays  in,  553-555. 
Warnings  given  by  X-ray  examinations.  305-309. 
Warts,  X-ray  treatment  of,  672. 
Washer  use4  for  locating  point  on  skin,  87. 
Water,  and  ascitic  fluid,  experiment  with,  6. 
radiograph  of,  5. 

sterilized,  injected  in  empyema,  241. 
Wax,  melting  of,  by  sun,  overcome,  553-554. 
Wehnelt's  electrolytic  interrupter,  20,  24,  637. 
Weinberger,  Dr.,  356,  654. 
Werner,  reports  by,  on  therapeutic  uses  of  X-rays, 

419.  445- 
Wheatstone  stereoscope,  471. 
Whistle  in  cesophagus,  radiograph  of,  541. 

in  pelvis,  radiograph  of,  551. 
Width  of  heart,  260. 

errors  to  be  avoided  in  measuring,  263. 
Wilbert,  on  use  of  X-rays  in  cases  of  fracture, 

467-468. 
Willard,    De   F.,   report   of,    on    radiographs    of 
tuberculous  knees,  594. 


INDEX 


/D/ 


Williams,  Dr.  Charles  H.,  use  of  X-rays  in  locat- 
ing foreign  body  in  eye  by,  538-539. 
Williams,  Dr.  Francis  H.,  references  to  articles 
published  by,  5,  49,  106  n.,  iii,  113,  142, 
202,    222,    247,    249,    258,    260,   262,   423, 
532. 
Wimshurst  influence  machine,  8,  637. 
Women,  average  weight  of  heart  of,  ^73-275. 
heart  more  to  the  left  in,  than  in  men,  260. 
Wood  transparent  to  X-rays,  2. 
Woods,  Dr.  Richard    F.,  report   of,   concerning 

case  of  lupus  erythematosus,  713. 
Wright,  J.  H.,  435. 

Wrist,  fracture  of,  at  Boston  City  Hospital,  456. 
method  of  photographing  fracture  of,  488. 
photographing  the,  98. 
radiographs  of  needle  in,  548,  549. 
tuberculous,  treatment  of,  by  X-rays,  419. 
Wrist-joint,  radiographs  of,  457. 
\\'yss,  Robert  von,  investigation  of  development 
of  skeleton   in  cretins  and  cretinoids  by, 

461-462. 

^^ 

X-ray,  apparatus,  portable  forms  of,  27,  638. 

department  at  hospitals,  635,  636. 
X-rays,  dental  uses  of,  603-614. 

medico-legal  uses  of,  634. 

military  uses  of,  553-555. 

mode  of  action  of,  393. 

origin  and  nature  of,  i. 

introduction  to  surgical  uses  of,  454-458. 

therapeutic  uses  of,  391-453,  654-719. 
X-ray  tracings,  77-79,  126. 

transferred  to  blanks  for  record,  79-80,  174. 


X-ray  tracings  and  records  of  appearances  in  — 
bronchitis,  201. 
cancer  of  liver,  376. 
chest  (normal),  102,  107. 
dextrocardia,  652. 

heart,  errors  to  be  avoided  in  recording  X-ray 
outlines,  266-268. 

displacement  of,  by  diaphragm  and  dis- 
tended abdomen,  287. 
displacement  of,  289,  29(1,  292-294,  297. 
effect  of  treatment  observed,  302-303. 
inaccuracy  of  percussion  shown,  280- 
285. 
new  growths,  324-336,  338,  342,  344-345,  348, 

350-351- 
pleurisy  with  effusion,  206,  208,  210-212,  214- 

215,  217,  219,   221,  223-225,   226-227,  229, 

231-232,  648. 
pneumonia,  169,  171,  172,  174,   176-179,  181, 

182-184,  187,  189-190. 
pneumohydrothorax,  243,  245. 
pneumothorax,  236-239. 
pulmonary  tuberculosis,    116,    126,    128,    131, 

132,  133.  136,  137,  138,  150-154- 
pulmonary  tuberculosis  suspected  by  physical 

signs  not  indicated  by  X-rays,  145. 
stomach  during  digestion,  361-371. 
subdiaphragmatic  abscess,  654. 
thoracic  aneurisms,  316,  318-321,  323,  326-327. 


Zadek  on  echinococcus  of  the  lung,  346. 
Zinn  on  persistence  of  ductus  arteriosus  Botalli, 
301. 


IMPERATIVE   SURGERY 

For  the  general  practitioner,  the  specialist,  and  the  recent  graduate.  Bv  Howxkd 
LILIEXTHAL,  Attending  Surgeon,  Mt.  Sinai  Hospital,  New  York  Citv,  with  nL>mcrou« 
original  illustrations  from  photographs  and  drawings.  Cloth.  Square  8vo,  ?4.oo.  net" 
Half  morocco.  Square  8vo,  $5.00,  net. 

"Dr.  Lilienthal  has  limited  his  work  to  what  are  ordinarily  known  as  emergency  operations  • 
that  IS,  to  the  description  of  the  technics  of  surgical  procedure  in  conditions  which  demand  active  and 
immediate  surgical  intervention.     It  is  in  this  respect  that  his  book  is  unique  in  surgical  literature 

"The  chapters  on  abdominal  surgery  are  especially  complete, and,  as  we  shall  suhse-iuentiv  point 
out,  are  superbly  illustrated.  Under  the  description  of  each  operation  there  is  a  full  statement  in 
detail  of  the  after-treatment.  This  includes  not  only  the  care  of  the  patient  imme.hatelv  l„ll..wing 
the  operation,  but  his  subsequent  treatment,  covering  the  time  for  removal  of  sutures  and  fur  change 
of  dressings.     The  importance  of  this  feature  of  the  book  is  self-evident. 

"  The  text  throughout  is  marked  by  earnestness  and  thoroughness.  There  is  no  ambiguitv  of  pro- 
cedure ;  the  reader  is  not  left  to  choose  any  one  of  several  methods.  The  choice  is  made  for  him, 
and  this  is  done  in  a  literary  style  which  is  exceptionally  lucid  and  concise,  the  impression  that  is 
made  by  reading  the  book  is  one  of  complete  subordination  of  the  unessential  to  the  necessary,  of  a 
mass  of  detail  which  is  clearly  set  forth  and  as  clearly  elucidated,  and,  finally,  of  an  epitome  of  an 
individual  surgeon's  experience  in  a  branch  of  the  art  which,  perhaps,  is  the  widest  in  the  saving  of  life. 

"  It  is  necessary  to  speak  of  the  illustrations,  which  are  not  only  numerous,  but  of  a  character 
rarely  encountered  in  medical  books.  Many  are  made  from  photographs,  others  from  drawings  ;  but 
the  distinguishing  feature  which  characterizes  them  is  their  remarkable  clearness.  .  .  . 

"  It  is  scarcely  too  much  to  say  that  since  Dr.  Lilienthal's  book  fills  an  unoccupied  place  in  sur- 
gical literature,  and  because  it  is  altogether  scientific  and  modern,  it  must  prove  one  of  the  suc- 
cessful books  of  the  year." — Extracts  from  an  extended  review  in  the  A'ero  York  Medical  Journal, 
March  17,  igoo. 


A  MANUAL  OF   SURGERY 

By  Charles  Stonham,  F.R.C.S.,  Eng..  Senior  Surgeon  to  the  Westminster  Hospital; 
also  Lecturer  on  Surgery  and  Clinical  Surgery,  and  Teacher  of  Operative  Surgery ; 
Surgeon  to  the  Poplar  Hospital  for  Accidents ;  Examiner  in  Surgery.  Society  of 
Apothecaries.  London,  etc.,  etc.  Fully  illustrated.  Three  volumes.  Cloth,  i2mo, 
$6.00,  net.     Vol.  I,  General  Surgery.     Vol.  II.  Injuries.     Vol.  Ill,  Regional  Surgery. 

The  work  is  notably  modern,  and  as  such  much  that  is  of  historical  interest  merely  has  been 
purposely  omitted,  since  it  is  undesirable  to  clog  a  work  intended  for  immediate  daily  use  with 
material  which  is  out  of  date  so  far  as  actual  practice  is  concerned  and  is  readily  accessijjle  in 
printed  w'orks  for  those  who  would  follow  up  the  historic  side  of  the  subject. 

No  better  aid  can  be  found  for  the  student  or  for  the  general  practitioner  who- wishes  to  review 
the  very  latest  of  the  new  discoveries  in  both  the  theory  and  method  of  treating  surgically  pathologi- 
cal conditions. 


THE    MACMILLAN    COMPAXV 

66    FIFTH    AVENUE,  NEW    YORK    CITY 


THE   PRACTITIONER'S   HANDBOOK   OF   TREATMENT;    OR, 
THE   PRINCIPLES   OF   THERAPEUTICS 

By  the  late  J.  Milner  Fothergill,  M.D.,  M.R.C.P.,  Foreign  Associate  Fellow  of  the  Col- 
lege of  Physicians  of  Philadelphia.  Fourth  edition.  8vo.  Cloth.  $5.00.  Edited,  and 
in  great  part  rewritten,  by  William  Murrell,  M.D.,  F.R.C.P. 

The  enormous  progress  in  all  departments  of  metlicine  during  the  last  ten  3-ears  has  necessi- 
tated a  thorough  revision  of  the  work.  Considerable  additions  have  been  made,  but  Dr.  Fothergill's 
original  design,  and,  above  all,  his  characteristic  style,  have  as  far  as  possible  been  preserved. 

In  the  Preface  to  the  First  Edition  of  this  work.  Dr.  Milner  Fothergill  points  out  that  it  is  not 
"  an  imperfect  practice  of  physic,  but  an  attempt  of  original  character  to  explain  the  rationale  of  our 
therapeutic  measures  .  .  .  and  "  is  a  work  on  medical  tactics  for  the  bedside  rather  than  the 
examination  table." 

The  Lancet,  in  its  obituary  notice  of  Dr.  Fothergill,  states  that  "  in  his  profession  he  exhibited 
great  natural  skill  in  interpreting  the  indications  for  treatment  of  disease,  and  in  many  cases  of  ditifi- 
culty  he  would  clear  up  the  lines  of  treatment  with  a  hand  that  was  felt  to  be  masterly.  .  .  .  He 
always  wrote  what  was  instructive  in  a  vivacious  and  interesting,  oftentimes  original  and  pungent, 
style." 


INTRODUCTION   TO   THE   OUTLINES   OF   THE   PRINCIPLES 
OF   DIFFERENTIAL   DIAGNOSIS 

With  Clinical  Memoranda,  by  Fred  J.  Smith,  Senior  Pathologist  to  the  London  Hospital. 
Ex.  Cr.     8vo.     $2.00. 


DIABETES  MELITUS  AND  ITS  TREATMENT 

By  R.  T.  Williamson,  JVI.D.  (Lond.),  M.R.C.P.,  Medical  Registrar,  Manchester  Royal 
Infirmary ;  Hon.  Med.  Officer,  Pendleton  Dispensary  (Salford  Royal  Hospital)  ;  Assist- 
ant to  the  Professor  of  Medicine.  Owens  College,  ]\Ianchester.  W^ith  18  illustrations 
(two  colored).     Royal  8vo.     Cloth.     $4.50. 

"  The  study  of  diabetes,  which  formed  the  basis  of  the  author's  discovery  of  the  discoloration  of 
methylene  blue  by  blood  taken  from  a  diabetic  subject,  has  made  his  name  well  known  in  connection 
with  this  disease.  A  contribution  from  his  pen,  in  the  form  of  a  monograph  upon  diabetes,  is  bound 
to  be  interesting.  In  the  work  before  us,  we  find  a  more  thorough  consideration  of  the  subject  than 
has  yet  appeared  in  the  English  language.  The  chapters  devoted  to  symptomatology  and  complica- 
tions are  particularly  full  and  thorough.  The  treatment  of  the  disease  is  excellently  handled,  and 
closes  the  work  in  a  thoroughly  practical  manner.  The  bibliography  attached  to  each  chapter  and 
an  appendix  on  diabetic  dietetics  add  value  to  a  work  which  in  completeness  and  didactic  worth  is 
unexcelled."  —  N.  Y.  Medical  News. 


THE    MACMILLAN    COMPANY 

66    FIFTH    AVENUE,  NEW    YORK    CITY 


A 


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UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


JUL  2  4  1968 


JO 


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BIOMED.  LIB. 

'    AUG    3  1971 
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Form  L9-40to-5,'67(H2161s8)4939 

FEB  2  8REC'D 


